Brief interventions database

The ODHINbrief interventions database developed built on work undertaken in the PHEPA Project and the research performed by the ODHIN scientists to provide information on identification and brief intervention (IBI) programmes in the following topics categories (click on a title to see information and evidence related to the topic):

Health effects

Alcohol and disease

Key Finding

Alcohol consumption is a wholly or contributory cause for more than 200 diseases, injuries and other health conditions with ICD-10 codes.

Commentary

For most diseases and injuries, there is a dose–response relationship with alcohol.Not only the volume of alcohol consumed, but also the pattern of drinking over time affects the risks of harm. Patterns of drinking are linked to injuries (both unintentional and intentional) and risk of cardiovascular diseases (mainly ischaemic heart disease and ischaemic stroke). The cardio-protective effect of low-risk patterns of alcohol consumption disappears completely in the presence of heavy episodic drinking.

Age, gender and socio-economic status impact the relationship between alcohol consumption and harm. Children, adolescents and older people are more vulnerable to alcohol-related harm from a given volume of alcohol than other age groups.   An increased burden of alcohol-related disease among men is largely explained by the fact that compared to women, men are less often abstainers, drink more frequently and in larger quantities. When the number of health and social consequences is considered for a given level of alcohol use or drinking pattern, sex differences for social outcomes reduce significantly or even reverse. One explanation is the higher prevalence of injuries among men; however, for health outcomes such as cancers, gastrointestinal diseases or cardiovascular diseases, the same level of consumption leads to more pronounced outcomes for women. In addition, women who drink during pregnancy may increase the risk of foetal alcohol spectrum disorder, and other preventable health conditions in their new-borns.

Surveys indicate that there are more drinkers, more drinking occasions and more drinkers with low-risk drinking patterns in higher socioeconomic groups, while abstainers are more common in the poorer social groups. However, people with lower socioeconomic status are more vulnerable to tangible problems and consequences of alcohol consumption. One explanation for the potentially greater vulnerability among lower socioeconomic groups is that they are less able to avoid adverse consequences of their behaviour due to a lack of resources. For example, individuals with higher socioeconomic status may be more able to choose safer environments in which to drink, purchase social or spatial buffering of their behaviour, and have better access to high-quality health care services.  

Major disease and injury categories causally impacted by alcohol consumption

Neuropsychiatric conditions: alcohol use disorders are the most important neuropsychiatric conditions caused by alcohol consumption. Epilepsy is another disease causally impacted by alcohol, over and above withdrawal-induced seizures. Alcohol consumption is associated with many other neuropsychiatric conditions, such as depression or anxiety disorders, but the complexity of the pathways of these associations currently prevents their inclusion in the estimates of alcohol-attributable disease burden.

Gastrointestinal diseases: liver cirrhosis and pancreatitis (both acute and chronic) are causally related to alcohol consumption. Higher levels of alcohol consumption create an exponential increase in risk. The impact of alcohol is so important that for both disease categories there are subcategories which are labelled as “alcoholic” or “alcohol-induced” in the ICD.

Cancers: alcohol consumption has been identified as carcinogenic for the following cancer categories cancer of the mouth, nasopharynx, other pharynx and oropharynx, laryngeal cancer, oesophageal cancer, colon and rectum cancer, liver cancer and female breast cancer. In addition, alcohol consumption is likely to cause pancreatic cancer. The higher the consumption, the greater the risk for these cancers, with consumption as low as one drink per day causing significantly increased risk for some cancers, such as female breast cancer.

Intentional injuries: alcohol consumption, especially heavy drinking, has been causally linked to suicide and violence.

Unintentional injuries: almost all categories of unintentional injuries are impacted by alcohol consumption. The effect is strongly linked to the alcohol concentration in the blood and the resulting effects on psychomotor abilities. Higher levels of alcohol consumption create an exponential increase in risk.

Cardiovascular diseases (CVD): the relationship between alcohol consumption and cardiovascular diseases is complex. The beneficial cardioprotective effect of relatively low levels of drinking for ischaemic heart disease and ischaemic stroke disappears with heavy drinking occasions. Moreover, alcohol consumption has detrimental effects on hypertension, atrial fibrillation and haemorrhagic stroke, regardless of the drinking pattern.

Fetal alcohol syndrome (FAS) and preterm birth complications: alcohol consumption by an expectant mother may cause these conditions that are detrimental to the health of a newborn infant.

Diabetes mellitus: a dual relationship exists, whereby a low-risk pattern of drinking may be beneficial while heavy drinking is detrimental.

Infectious diseases: harmful use of alcohol weakens the immune system thus enabling development of pneumonia and tuberculosis. This effect is markedly more pronounced when associated with heavy drinking, and there may be a threshold effect, meaning that disease symptoms manifest mainly if a person drinks above a certain level of heavy drinking.

 

Supporting evidence

Grittner U, Kuntsche S, Graham K, Bloomfield K (2012). Social inequalities and gender differences in the experience of alcohol-related problems. Alcohol Alcohol. 47:597–605. doi: 10.1093/alcalc/ags040.

Roerecke M, Rehm J (2010). Irregular heavy drinking occasions and risk of ischemic heart disease: A systematic review and meta-analysis. Am J Epidemiol. 171:633–44. doi: 10.1093/aje/kwp451.

World Health Organization (2014). Global status report on alcohol and health 2014. Geneva: World Health Organization.

Alcohol and risk of death

Key Finding

The risk of dying form an alcohol-related condition increases with increasing alcohol consumption, with no level that is risk free

Commentary

A European study estimated the risk of dying from alcohol before the age of 70 years related to daily alcohol consumption for European men and women. Combining the risk of death from disease and the risk of death from injuries, the risk of death increased with the level of alcohol consumption for both men and women, with beyond about 30 grams of alcohol a day, the risk for men greater than the risk for women at any given level of alcohol consumption. At a consumption level of 60 grams a day, there was nearly a 4% chance for women dying from alcohol before the age of 70 years, and more than a 5% chance for men.

Risk of dying prematurely (up to age 70) due to alcohol consumption by drinking level in grams of pure alcohol per day (average for 6 EU countries based on mortality profile for 2012).

risk of dying prematurely

 

Supporting evidence

Rehm, J., Lachenmeier, DW, Room R. Acceptable risk? Why does society accept a higher risk for alcohol than for other voluntary or involuntary risks? BMC Medicine 2014. http://www.biomedcentral.com/1741-7015/12/189.Accessed 12 November 2014.

Identifying hazardous and harmful alcohol consumption

Alcohol Use Disorders Identification Test (AUDIT)

Key finding

AUDIT (Alcohol Use Disorders Identification Test) is effective in the identification of hazardous and harmful drinking in adults in primary care.

Commentary
AUDIT is effective in the identification of hazardous and harmful drinking in adults in primary care (1-6). Optimal screening thresholds for the detection of hazardous or harmful drinking using AUDIT seem to vary with age, sex and country (1,8-11). Thresholds appeared to be ≥6 to ≥8 in both sexes (1,2,4,5,8-11). Nevertheless, lower thresholds are usually advocated for women (4,7,11). AUDIT also demonstrated a higher sensitivity (when used at an optimal cut-off of ≥3) than CAGE, CRAFFT or POSIT in the detection of hazardous/harmful consumption in a sample aged between 14 and 18 years (12).

Supporting evidence

(1)Berks J, McCormick R. (2008).  Screening for alcohol misuse in elderly primary care patients: a systematic literature review. International Psychogeriatrics, 20(6): 1090-103.

(2)Fiellin D, Reid M, O'Connor P. (2000). Screening for alcohol problems in primary care: a systematic review. Archives of Internal Medicine, 160(13): 1977-89. 

(3)Reinert D, Allen J. (2007). The Alcohol Use Disorders Identification Test: An update of research findings. Alcoholism: Clinical & Experimental Research. 31(2): 185-99.

(4)Aalto M, Tuunanen M, Sillanaukee P, Seppa K. (2006). Effectiveness of structured questionnaires for screening heavy drinking in middle-aged women. Alcoholism: Clinical & Experimental Research, 30(11): 1884-8.

(5)Coulton S, Drummond C, James D, Godfrey C, Bland J, Parrott S, et al. (2006). Opportunistic screening for alcohol use disorders in primary care: comparative study. BMJ, 332(7540): 511-7. 

(6) Sovinová H, Csémy L. (2010). The Czech AUDIT: internal consistency, latent structure and identification of risky alcohol consumption. Cent Eur J Public Health, 18(3): 127-31.

(7)Aertgeerts B, Buntinx F, Ansoms S, Fevery J. (2001). Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. British Journal of General Practice, 51(464): 206-17.

(8) de Torres L, Rebollo E, Ruiz-Moral R, Fernández-García J, Vega R, Palomino M. (2009). Diagnostic usefulness of the Alcohol Use Disorders Identification Test (AUDIT) questionnaire for the detection of hazardous drinking and dependence on alcohol among Spanish patients. Eur J Gen Pract, 15: 15-21.

(9) Moretti-Pires R, Corradi-Webster C. (2011). Adaptation and validation of the Alcohol Use Disorders Identification Test (AUDIT) for a river population in the Brazilian Amazon. Cad Saúde Pública, 27(3): 497-509.

(10) Alvarado M, Garmendia M, Acuña G, Santis R, Arteaga O. (2009). Assessment of the Alcohol Use Disorders Identification Test (AUDIT) to detect problem drinkers. Rev Méd Chile, 137: 1463-8.

(11)Bradley K, Boyd-Wickizer J, Powell S, Burman M. (1998). Alcohol screening questionnaires in women: a critical review. JAMA, 280(2): 166-71.

(12) Knight J, Sherritt L, Harris S, Gates E, Chang G. (2003). Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcoholism: Clinical & Experimental Research, 27(1): 67-73.

Short version of AUDIT

Key finding

Shorter versions of AUDIT are effective in the identification of hazardous and harmful drinking in adults in primary care.

Commentary

Shorter versions of AUDIT are effective in the identification of hazardous and harmful drinking in adults in primary care (1-3). AUDIT’s high internal consistency allowed abbreviated versions to be just as efficient as the full version (4). The optimal screening threshold for the detection of hazardous drinking using AUDIT-C appeared to be ≥3 to ≥5 among men (5,7) and ≥3 to ≥4 among women (5-7). FAST is described as having a sensitivity of 97% and a specificity of 91% for the detection of alcohol problems at a cut-off point of 1 in males and females in a primary care setting (8).

Supporting evidence

(1) Aalto M, Tuunanen M, Sillanaukee P, Seppa K. (2006). Effectiveness of structured questionnaires for screening heavy drinking in middle-aged women. Alcoholism: Clinical & Experimental Research, 30(11): 1884-8.

(2) Bradley K, DeBenedetti A, Volk R, Williams E, Frank D,  Kivlahan D. (2007). AUDIT-C as a brief screen for alcohol misuse in primary care. Alcoholism: Clinical & Experimental Research, 31(7): 1208-17.

(3) Tuunanen M, Aalto M, Seppa K. (2007). Binge drinking and its detection among middle-aged men using AUDIT, AUDIT-C and AUDIT-3. Drug & Alcohol Review, 26(3): 295-9.

(4) Meneses-Gaya C, Zuardi A, Loureiro S, Hallak J, Trzesniak C, Marques J, et al. (2010). Is the full version of the AUDIT really necessary? Study of the validity and internal construct of its abbreviated versions. Alcoholism: Clinical & Experimental Research, 34(8): 1417-24.

(5) Berks J, McCormick R. (2008).  Screening for alcohol misuse in elderly primary care patients: a systematic literature review. International Psychogeriatrics, 20(6): 1090-103.

(6) Frank D, DeBenedetti A, Volk R, Williams E, Kivlahan D, Bradley K. (2008). Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups. Journal of General Internal Medicine, 23(6): 781-7.

(7) Gual A, Segura L, Contel M, Heather N, Colom J. (2002). Audit-3 and audit-4: effectiveness of two short forms of the alcohol use disorders identification test. Alcohol Alcohol, 37(6):591-6.

(8) Reinert D, Allen J. (2007). The Alcohol Use Disorders Identification Test: An update of research findings. Alcoholism: Clinical & Experimental Research. 31(2): 185-99.

CAGE screening questionnaire

Key finding

CAGE is effective in the detection of alcohol dependence in adults in primary care.

Commentary

CAGE is effective in the detection of alcohol dependence in adults in primary care (1-3). Optimal thresholds for screening for alcohol dependence using CAGE in primary care appeared to be ≥1 or ≥2 for adult men (1-3) and non-pregnant women (1-5).

Supporting evidence

(1) Berks J, McCormick R. (2008).  Screening for alcohol misuse in elderly primary care patients: a systematic literature review. International Psychogeriatrics, 20(6): 1090-103.

(2) Fiellin D, Reid M, O'Connor P. (2000). Screening for alcohol problems in primary care: a systematic review. Archives of Internal Medicine, 160(13): 1977-89.

(3) Aertgeerts B, Buntinx F, Ansoms S, Fevery J. (2001). Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. British Journal of General Practice, 51(464): 206-17.

(4) Frank, D., DeBenedetti, A. F., Volk, R. J., Williams, E. C., Kivlahan, D. R., & Bradley, K. A. (2008). Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups. Journal of General Internal Medicine, 23(6): 781-7.

(5) Burns E, Gray R, Smith L. (2010). Brief screening questionnaires to identify problem drinking during pregnancy - a systematic review. Addiction, 105(4): 601-14.

Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

Key finding

The ASSIST screening questionnaire shows promise and is appropriate for use for the detection of harmful drinking and alcohol dependence among adults in primary care.

Commentary

Limited evidence demonstrates that the ASSIST screening questionnaire shows promise and is appropriate for the detection of harmful drinking and alcohol dependence among adults in primary care (1-5).

Supporting evidence

(1) WHO ASSIST Working Group. (2002). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction, 97(9): 1183-94.

(2) Newcombe D, Humeniuk R, Ali R. (2005). Validation of the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): report of results from the Australian site. Drug & Alcohol Review, 24(3): 217-26.

(3) Humeniuk R, Ali R, Babor T, Farrell M, Formigoni M, Jittiwutikarn J, et al. (2008). Validation of the Alcohol, Smoking And Substance Involvement Screening Test (ASSIST). Addiction, 103(6): 1039-47.

(4) Khan R, Chatton A, Nallet A, Broers B, Thorens G, Achab-Arigo S, et al. (2011). Validation of the French version of the alcohol, smoking and substance involvement screening test (ASSIST). Eur Addict Res, 17(4): 190-7.

(5) Khan R, Chatton A, Thorens G, Achab S, Nallet A, Broers B, et al. (2012). Validation of the French version of the alcohol, smoking and substance involvement screening test (ASSIST) in the elderly. Subst Abuse Treat Prev Policy, 20;7:14.

Fast Alcohol Screening Test (FAST)

Key finding

FAST displays good screening properties in the identification of alcohol problems among males and females presenting to accident and emergency (A&E) settings.

Commentary

FAST displays good screening properties in the identification of alcohol problems among males and females presenting to accident and emergency (A&E) settings (1). Whilst no evidence could be identified that directly compared the performance of the Paddington Alcohol Test with other alcohol screening measures in A&E, this tool has been shown to be rapid, feasible to use (2-5), and to be as effective as AUDIT which indicates its greater adequacy for health care services requiring faster assessment (6).

Supporting evidence

(1) Reinert D, Allen J. (2007). The Alcohol Use Disorders Identification Test: An update of research findings. Alcoholism: Clinical & Experimental Research. 31(2): 185-99.

(2) Huntley J, Blain C, Hood S, Touquet R. (2001).  Improving detection of alcohol misuse in patients presenting to an accident and emergency department. Emergency Medicine Journal, 18: 99-104.

(3) Patton R, Touquet R. (2002). The Paddington Alcohol Test. British Journal of General Practice, 52(474): 59.

(4) Patton R, Crawford M, Touquet R. (2003). Impact of health consequences feedback on patients acceptance of advice about alcohol consumption. Emergency Medicine Journal, 20(5): 451-2.

(5) Patton R, Hilton C, Crawford M, Touquet R, (2004). The Paddington Alcohol Test: a short report. Alcohol & Alcoholism, 39(3): 266-8.

(6) Meneses-Gaya C, Crippa J, Zuardi A, Loureiro S, Hallak J, Trzesniak C, et al. (2010). The fast alcohol screening test (FAST) is as good as the AUDIT to screen alcohol use disorders. Subst Use Misuse, 45(10): 1542-57.

AUDIT and alcohol dependence

Key finding

AUDIT can be used to identify alcohol dependence.

Commentary

AUDIT can be used to identify alcohol dependence in adults (1-3) and seems to perform better than CAGE to identify past-year alcohol dependence (2). AUDIT has shown to perform more effectively in the identification of alcohol dependence (when used at a cut-off of 10) than CAGE, CRAFFT or RAPS-QF in young people (4).

Supporting evidence

(1) de Torres L, Rebollo E, Ruiz-Moral R, Fernández-García J, Vega R, Palomino M. (2009). Diagnostic usefulness of the Alcohol Use Disorders Identification Test (AUDIT) questionnaire for the detection of hazardous drinking and dependence on alcohol among Spanish patients. Eur J Gen Pract, 15(1): 15-21.

(2) Rubinsky A, Kivlahan D, Volk R, Maynard C, Bradley K. (2010). Estimating risk of alcohol dependence using alcohol screening scores. Drug Alcohol Depend, 108(1-2): 29-36.

(3) Alvarado M, Garmendia M, Acuña G, Santis R, Arteaga O. (2009). Assessment of the alcohol use disorders identification test (AUDIT) to detect problem drinkers. Rev Med Chil, 137(11): 1463-8.

(4) Kelly T, Donovan J, Chung T, Cook R, Delbridge T. (2004). Alcohol use disorders among emergency department-treated older adolescents: a new brief screen (RUFT-Cut) using the AUDIT, CAGE, CRAFFT, and RAPS-QF. Alcoholism: Clinical & Experimental Research, 28(5): 746-53. 

TWEAK and T-ACE screening questionnaires

Key finding

The screening questionnaires TWEAK and T-ACE are both appropriate for the identification of alcohol diagnoses during pregnancy.

Commentary

The screening questionnaires TWEAK, T-ACE and AUDIT-C are appropriate for the identification of alcohol diagnoses during pregnancy (1-5). AUDIT performed significantly better than T-ACE as a predictor of lifetime alcohol diagnoses and current drinking (2,5). TWEAK and T-ACE seem to be more effective than CAGE in detecting risky drinking during pregnancy (4,5). TWEAK and T-ACE displayed optimal combinations of sensitivity and specificity at a cut-off point of 2 (4). The detection of children with neurobehavioral effects related to pre-natal alcohol exposure as also been shown to be possible with T-ACE (6).

Supporting evidence

(1) Burd L, Martsolf J, Klug M, O'Connor E, Peterson M. (2003). Prenatal alcohol exposure assessment: multiple embedded measures in a prenatal questionnaire. Neurotoxicology and Teratology, 25(6): 675-9.

(2) Chang G, Wilkins-Haug L, Berman S, Goetz M, Behr H, Hiley A. (1998). Alcohol use and pregnancy: improving identification. Obstetrics & Gynecology, 91(6): 892-8.

(3) Dawson D, Das A, Faden V, Bhaskar B, Krulewitch C, Wesley B. (2001). Screening for high- and moderate-risk drinking during pregnancy: a comparison of several TWEAK-based screeners. Alcoholism: Clinical & Experimental Research, 25(9): 1342-9.

(4) Russell M, Martier S, Sokol R, Mudar P, Jacobson S, Jacobson J. (1996). Detecting risk drinking during pregnancy: a comparison of four screening questionnaires. American Journal of Public Health, 86(10): 1435-9.

(5) Burns E, Gray R, Smith L. (2010). Brief screening questionnaires to identify problem drinking during pregnancy - a systematic review. Addiction, 105(4): 601-14.

(6) Chiodo L, Sokol R, Delaney-Black V, Janisse J, Hannigan J. (2010). Validity of the T-ACE in pregnancy in predicting child outcome and risk drinking. Alcohol, 44(7-8): 595-603.

Laboratory markers

Key finding

Laboratory markers are of limited value in the detection of hazardous and harmful alcohol use when compared with alcohol screening questionnaires.

Commentary

Laboratory markers are of limited value in the detection of hazardous and harmful alcohol use when compared with alcohol screening questionnaires (1-4). Currently, biomarkers used in the clinic include non-protein as well as protein markers (5-10). Recent reports have highlighted the need for biomarker panels, rather than single biomarkers, to be used to accurately assess an individual’s drinking behaviour (5). Proteomic techniques allow for the analysis of many or all of the proteins in a given sample. The rise of proteomics in the alcohol abuse field holds great promise, as well as great challenges (5).

Supporting evidence

(1) Coulton S, Drummond C, James D, Godfrey C, Bland J, Parrott S, et al. (2006). Opportunistic screening for alcohol use disorders in primary care: comparative study. BMJ, 332(7540): 511-7.

(2) Aertgeerts B, Buntinx F, Ansoms S, Fevery J. (2001). Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. Br J Gen Pract, 51(464): 206-17.

(3) Bisson J, Milford-Ward A. (1994). A comparison of carbohydrate deficient transferrin with other markers of alcohol misuse in male soldiers under the age of thirty. Alcohol Alcohol, 29(3): 315-21.

(4) Wetterling T, Kanitz R, Rumpf H, Hapke U, Fischer D. (1998). Comparison of cage and mast with the alcohol markers CDT, gamma-GT, ALAT, ASAT and MCV. Alcohol Alcohol, 33(4): 424-30.

(5) Torrente M, Freeman W, Vrana K. (2012). Protein biomarkers of alcohol abuse. Expert Rev Proteomics, 9(4): 425-36.

(6) Isaksson A, Walther L, Hansson T, Andersson A, Alling C. (2011). Phosphatidylethanol in blood (B-PEth): a marker for alcohol use and abuse. Drug Test Anal, 3(4): 195-200.

(7) Imbert-Bismut F, Naveau S, Morra R, Munteanu M, Ratziu V, Abella A, et al. (2009). The diagnostic value of combining carbohydrate-deficient transferrin, fibrosis, and steatosis biomarkers for the prediction of excessive alcohol consumption. Eur J Gastroenterol Hepatol, 21(1): 18-27.

(8) Morini L, Politi L, Polettini A. (2009). Ethyl glucuronide in hair. A sensitive and specific marker of chronic heavy drinking. Addiction, 104(6): 915-20.

(9) Morini L, Colucci M, Ruberto M, Groppi A. (2012). Determination of ethyl glucuronide in nails by liquid chromatography tandem mass spectrometry as a potential new biomarker for chronic alcohol abuse and binge drinking behavior. Anal Bioanal Chem, 402(5): 1865-70.

(10) Pichini S, Marchei E, Vagnarelli F, Tarani L, Raimondi F, Maffucci R, et al. (2012). Assessment of prenatal exposure to ethanol by meconium analysis: results of an Italian multicenter study. Alcohol Clin Exp Res, 36(3): 417-24.

Efficacy of interventions

Effectiveness of brief advice for heavy drinking in primary health care

Key finding

Brief advice, when delivered in primary health care, is effective in reducing heavy drinking.

Commentary

A systematic review of 24 systematic reviews found that that brief advice for heavy drinking was effective (based on a definition of regular average consumption of more than 40g alcohol a day for women and more than 60g a day for men when delivered in primary health care settings.

Weekly alcohol consumption was the most commonly reported outcome, and a meta-analysis showed that compared with control conditions, brief advice reduced the quantity of alcohol drunk by 38 g per week (95%CI (confidence interval): 23-54g). When scored on a scale measuring degree of efficacy (a study performed under ideal conditions) or degree of effectiveness (a study performed in routine circumstances), no relationship is found between degree of efficacy or effectiveness and outcome. Systematic reviews and meta-analyses find significant reductions in control groups, suggesting that assessment procedures themselves may lead to reductions in alcohol consumption that also diminish differences between intervention and control groups.  

Delivery by a range of practitioners in primary healthcare settings has beneficial effects.

Although overall the evidence implies that brief advice for heavy drinking is equally effective in men and women, it is also the case that most studies to date have either focussed on male drinkers or not reported the data disaggregated by sex.

Further, whilst brief advice for heavy drinking appears to improve alcohol-related outcomes for adults aged eighteen years and over, evidence on effectiveness at either end of the age spectrum is less conclusive. Previous research (predominantly conducted in US-based college settings) suggests that effects appear less long-lived for young adults and college-age students, and there is insufficient evidence of effectiveness in both adolescents and older adults.

There is limited consideration of the impact of socio-economic status on the effectiveness of brief advice for heavy drinking.

Finally, in terms of the existing health status of participants, a number of reviews suggest that brief advice for heavy drinking is most impactful in non-treatment seeking, non-dependent patient populations.

Research shows that effect sizes are largest at the earliest follow-up points, with decay in intervention effects over time. In addition, although recent evidence suggests that greater effect sizes may be achieved with brief multi-contact interventions (each contact up to 15 minutes), compared with very brief (up to 5 minutes) and brief (more than 5 minutes, up to 15 minutes) single-contact interventions, in general, it seems that longer (more intensive) brief interventions offer no significant additional benefit over shorter input.

Supporting evidence

Jonas DE, Garbutt JC, Brown JM, Amick HR, Brownley KA, Council CL, et al. Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse. Comparative Effectiveness Review No. 64. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. Accessed at www.ncbi .nlm.nih.gov/books/NBK99199/ on 16 April 2013.

Kaner EF, Dickinson HO, Beyer FR, Campbell F, Schlesinger C, Heather N, Saunders JB, Burnand B, Pienaar ED. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004148. DOI: 10.1002/14651858.CD004148.pub3.

Moyer, A, Finney, JW, Swearingen, CE and Vergun, P (2002) Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97, 279-292.

ODonnell, A., Anderson, P., Newbury-Birch, D., Schulte, B., Schmidt, C., Reimer, J. & Kaner, E. The Impact of Brief Alcohol Interventions in Primary Healthcare: A Systematic Review of Reviews. Alcohol and Alcoholism doi: 10.1093/alcalc/agt170.

 

Cost-effectiveness of brief advice for heavy drinking in primary health care

Key finding

Brief advice, when delivered in primary health care, is cost-effective in reducing heavy drinking.

Commentary

In England, screening patients with AUDIT-C on registration with a family doctor would steadily capture about 40% of the population over a 10-year programme. The registration approach, delivered by a practice nurse with subsequent five minutes of brief advice, would cost the health service £95 million over 10 years, offset by savings to the health care system of £215 million over 30 years (i.e., a net save of £120 million over 30 years). Health gains over the same period amount to 32,000 quality-adjusted life years (QALYs, which, taking into account both the quantity and quality of life generated by healthcare interventions, is the arithmetic product of life expectancy and a measure of the quality of the remaining life-years), with a cost-effectiveness of £6900 per QALY gained compared with no programme. In contrast, screening patients with the full AUDIT at next primary health care consultation would capture 96% of the population over a ten year period, but with high resourcing needs in the first year. The consultation approach, delivered by a doctor with subsequent five minutes of brief advice, would cost the health service £702 million over 10 years, offset by savings to the health care system of £594 million over 30 years (i.e., a net cost of £108 million over 30 years). Health gains over the same period amount to 92,000 QALYs, with an incremental cost-effectiveness ratio of £1175 per QALY gained compared with current practice.

In Italy, the population coverage for a programme of screening at next GP registration is estimated to be 63% of the total adult population, leading to 32% of people receiving a brief intervention during the 10 years of the programme. Coverage is spread relatively evenly across the 10 years, peaking in year 1 with 11% of the population being screened. A programme of screening at next consultation is estimated to capture 97% of the population over 10 years, with 49% of adults receiving an intervention as a result; however this is heavily loaded towards the start of the programme, with 84%% of people being screened in the first year. Over the course of 30 years, a programme of screening at next GP registration is estimated to result in 7200 fewer alcohol-attributable deaths, predominantly amongst men (66%) and from chronic (68%), rather than acute causes. The total number of hospitalisations saved by the programme is estimated to be 91,700, also largely amongst men (72%) and for chronic conditions (67%). The cost of delivering the programme over ten years is estimated to be 411 million. This is offset by a total reduction in hospital costs over 30 years of 370 million. The total gain in QALYs is estimated to be 75,200 giving an incremental cost-effectiveness ratio (ICER) of 550/QALY, suggesting that such a programme is close to being cost-neutral. As a large proportion of the health benefits are experienced by men (69% of total QALYs), delivering programmes to men only is estimated to be cost-saving, although the estimated ICER for a female-only programme of 3100/QALY is still well within the recommended Italian threshold of 25000-40000/QALY. As a programme at next GP consultation has a wider coverage, it is estimated to produce even greater improvements in public health, with 12,400 fewer alcohol-attributable deaths and 153,700 fewer hospital admissions over 30 years. The cost of delivery is also higher, at 687 million, although this is offset by cumulative healthcare savings of 605 million, making the programme around twice as expensive as screening at next registration. Health savings are estimated to be 139,200 additional QALYs, giving an ICER of 590/QALY and suggesting there is little to choose between the two programmes in terms of cost-effectiveness. It should be noted that as the majority of screening and brief advice takes place in the first year of the programme, the bulk of the delivery costs are incurred up front, whilst the health care savings are accrued over a longer time frame. This is in contrast to screening at next registration, where the costs are spread more evenly across the duration of the programme, Figure 1.

Figure 1 Cumulative net costs of modelled screening programmes (implementation costs less cost savings to healthcare provider) in Italy.

 Figure 1 Cumulative net costs of modelled

A programme of screening and brief advice at next GP registration or next consultation is also likely to be cost-effective in the Netherlands. The outcome measures observed were the costs of screening, the reduction in costs to the Dutch healthcare system as a result of reduced morbidity and mortality and the improvement in health outcomes measured in QALYs. The resulting incremental cost-effectiveness ratios for all scenarios suggest that either of the modelled programmes would be highly cost-effective when compared with a policy of no programme, under current Dutch guidelines, with a policy of screening and brief advice at next consultation, using the current AUDIT-C 5/4 screening tool bringing the greatest net benefit of all modelled options (at a willingness-to-pay threshold of €20,000/QALY). The cumulative net costs are plotted in Figure 2.

Figure 2 Cumulative net costs of modelled screening programmes (implementation costs less cost savings to healthcare provider) in Netherlands.

Figure 2 Cumulative net costs of modelled

A programme of SBIs at next GP registration or next consultation is also highly likely to be cost-effective in Poland. The outcome measures observed were the costs of screening, the reduction in costs to the Polish healthcare system as a result of reduced morbidity and mortality and the improvement in health outcomes measured in QALYs, in line with standard practice for economic evaluation. The resulting incremental cost-effectiveness ratios for all scenarios suggest that either of the modelled SBI programmes would be highly likely to be considered cost-effective when compared with a policy of no SBI, under current Polish guidelines, with a policy of SBI at next consultation, using the recommended AUDIT-C 5/4 screening tool bringing the greatest net benefit of all modelled options (at a willingness-to-pay threshold of 25000 zł/QALY). The cumulative net costs are plotted in Figure 3.

Figure 3 Cumulative net costs of modelled screening programmes (implementation costs less cost savings to healthcare provider) in Poland.

Figure 3 cumulative net costs of modelled

It should be noted that screening and brief advice programmes are estimated to be more expensive in countries with higher alcohol-related mortality, where more people will be captured by the programme and with lower alcohol-related morbidity rates. The health impact of screening and brief advice programmes is estimated to be greater in countries where alcohol consumption is greater and where more people are screened.

Supporting evidence

Angus, C. et al.: Cost-effectiveness of a programme of screening and brief interventions for alcohol in primary care in Italy. BMC Family Practice 2014 15:26. doi:10.1186/1471-2296-15-26.

Angus C, Scafato E, Ghirini S et al (2013) Cost-effectiveness-Model report. Deliverable 3.1. The ODHIN Consortium. 2013(published online: http://www.odhinproject.eu/resources/documents/doc_download/66-deliverable-3-1-cost-effectiveness-model-report.html

Purshouse R, Brennan A, Rafia R, Latimer NR, Archer RJ, Angus CR, Preston LR, Meier PS: Modelling the cost-effectiveness of alcohol screening and brief interventions in primary care in England. Alcohol Alcohol 2013, 48:180188.

Cost effectiveness

Key finding

Brief interventions in primary care settings are cost-effective.

Commentary

A recent systematic review, conducted as part of the ODHIN project, identified 23 studies which examined the cost-effectiveness of SBIs in primary care (1). Whilst the evidence on the optimal duration or delivery staff for the intervention was inconclusive, the overwhelming conclusion of the studies is that, irrespective of these factors, SBI programmes are cost-effective. The majority of this evidence comes from the USA, UK and Australia, although a growing number of studies have looked at other countries such as the Netherlands, Italy and Poland and the wider EU (2,3,4,5).

These conclusions match those of previous reviews of the cost-effectiveness evidence (6,7,8), providing strong evidence that SBIs in primary care are a cost-effective policy option for tackling alcohol-related harm.

Supporting evidence

(1) Angus, C., Latimer, N., Preston, L., Li, J. & Purshouse, R. (2014). What are the implications for policy makers? A systematic review of the cost-effectiveness of screening and brief interventions for alcohol misuse in primary care. Frontiers in Psychiatry. DOI 10.3389/fspyt.2014.00114

(2) Tariq, L., Van Den Berg, M., Hoogenveen, R.T. & Van Baal, P.H. (2009). Cost-effectiveness of an opportunistic screening programme and brief intervention for excessive alcohol use in primary care. PLoS One. DOI 10.1371/journal.pone.0005696

(3) Angus, C., Scafato, E., Ghirini, S., Torbica, A., Ferre, F., Struzzo, P., Purshouse, R. & Brennan, A. (2014). Cost-effectiveness of a programme of screening and brief interventions for alcohol in primary care in Italy. BMC Family Practice. DOI 10.1186/1471-2296-15-26

(4) Chisholm, D., Rehm, J., van Ommeren, M. & Monteiro, M. (2004). Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. Journal of Studies on Alcohol. 65:782-93

(5) Angus, C., Scafato, E., Ghirini, S., Torbica, A., Ferre, F., Struzzo, P., Keurhorst, M., Laurant, M., Słodownik, L., Okulicz-Kozaryn, K., Brzózka, K. & Brennan, A. (2013). Optimizing Delivery of Health Care Interventions (ODHIN): Cost-effectiveness – Model Report. Sheffield. Available from www.odhinproject.eu/resources/documents/doc_download/66-deliverable-3-1cost-effectiveness-model-report.html

(6) Ludbrook, A., Godfrey, C., Wyness, L., Parrott, S., Haw, S., Napper, M. & van Teilingen, E. (2001). Effective and cost-effective measures to reduce alcohol misuse in Scotland: a literature review. Aberdeen: Health Economics Research Unit. Available from www.alcoholinformation.isdscotland.org/alcohol_misuse/files/measurereduce_full.pdf

(7) Latimer, N., Guillaume, L. & Goyder, E. (2008). Prevention and early identification of alcohol use disorders in adults and young people. Screening and brief interventions: cost-effectiveness review. Sheffield. Available from www.sheffield.ac.uk/polopoly_fs/1.43294!/file/Alcohol-2_3.pdf

(8) Elzerbi, C., Donoghue, K. & Drummond, C. (2013). Report on the European public health impact and cost-effectiveness of early diagnosis and treatment of alcohol use disorders. Available from http://amphoraproject.net/w2box/data/Deliverables/AMPHORA_WP6_D3.3.pdf

Implementing brief intervention programmes

Support and resources

Key finding

Organisational factors such as adequate support and resources can influence the acceptability and implementation of screening and brief intervention for hazardous and harmful alcohol use.

Combining professional with patient oriented implementation strategies show optimal impact on provider screening and brief intervention behaviour.

Commentary

Organisational factors such as adequate support and resources can influence the acceptability and implementation of screening and brief intervention for hazardous and harmful alcohol use (1). Implementation of screening and brief intervention is influenced by factors other than effectiveness. Positive support from governments, management and involvement of non-clinical members of staff are more likely to result in successful implementation (2). Many professional oriented strategies are moderately effective (3). There is also evidence that adequate practitioner training, educational outreach visits and support in screening and use of brief intervention materials facilitates effective implementation as well as rates and appropriate detection of at risk drinkers (4-16) Financial incentives and successful management of staff changes as well as assistance from receptionists are also important. Concerning medical records, facilitating the record for screening and brief intervention can have significant influence on screening and brief intervention improvements (17). Furthermore, computerized feedback about: guidelines and consensus standards of care, individual goals, calculated performance rates and practitioner feedback about patients' smoking status, benzodiazepine use, blood pressure screening, cholesterol screening, and the delivery of program elements (Audit and feedback) improved the provider screening rate (18). But what is more, combining professional with patient oriented implementation strategies show optimal impact on provider screening and brief intervention behaviour (3).

However, barriers to success included competing priorities and lack of time. In general, training rates are low (19-22), and practitioners themselves perceive a lack of training (23-25).

Supporting evidence

(1) Anderson, P., Laurant, M., Kaner, E., Wensing, M., Grol, R., (2004). Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis. Journal of Studies on Alcohol, 65 (2): 191-199.

(2)
Babor, T. E., Higgins-Biddle, J., Dauser, D., Higgins, P., & Burleson, J. A. (2005). Alcohol screening and brief intervention in primary care settings: implementation models and predictors, Journal of Studies on Alcohol, 66 (3): 361-368.

(3) Keurhorst, M. et al. (Submitted). Determinants of successful implementation of screening and Advice for hazardous and harmful alcohol consumption in primary healthcare. A systematic review and meta-regression analysis of trials

(4) Adams, P. J., Powell, A., McCormick, R., & Paton-Simpson, G. (1997). Incentives for general practitioners to provide brief interventions for alcohol problems. New Zealand Medical Journal, 110 (1049): 291-294.

(5) Adams, A., Ockene, J. K., Wheller, E. V., & Hurley, T. G. (1998). Alcohol counseling: physicians will do it. Journal of General Internal Medicine. 13(10): 692-8.

(6) Kaner, E. F., Lock, C. A., McAvoy, B. R., Heather, N., & Gilvarry, E. (1999). A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners. British Journal of General Practice. 49 (446): 699-703.

(7) Kaner, E., Lock, C., Heather, N., McNamee, P., & Bond, S. (2003). Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial. Patient Education & Counseling. 51(3): 277-284.

(8) Berner, M. M., Ruf, D., & Harter, M. (2007). Diagnostic and treatment of alcohol-related disorders. Results of a representative survey in counseling centers. [German], Fortschritte der Neurologie-Psychiatrie. 75(2): 91-99.

(9) Funk, M., Wutzke, S., Kaner, E., Anderson, P., Pas, L., McCormick, R., Gual, A., Barfod, S., & Saunders, J. (2005). A multi country controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: Findings of a WHO Collaborative Study. Journal of Studies on Alcohol, 66: 379-388.

(10) Anderson, P., Kaner, E., Wutzke, S., Funk, M., Heather, N., Wensing, M., Grol, R., Gual, A. & Pas, L. (2004). Attitudes and managing alcohol problems in general practice: an interaction analysis based on Findings from a WHO Collaborative Study. Alcohol and Alcoholism, 39:351-356.

(11) Bradley KA, Epler AJ, Bush KR, Sporleder JL, Dunn CW, Cochran NE, et al. Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking. Journal of General Internal Medicine. 2002;17 (5):315-26.

(12) Friedmann PD, Rose J, Hayaki J, Ramsey S, Charuvastra A, Dube C, et al. Training primary care clinicians in maintenance care for moderated alcohol use. Journal of General Internal Medicine. 2006;21 (12):1269-75.

(13) Funk M, Wutzke S, Kaner E, Anderson P, Pas L, McCormick R, et al. A multicountry controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: findings of a World Health Organization collaborative study. J Stud Alcohol. 2005;66(3):379-88.

 (14) Kaner E, Lock C, Heather N, McNamee P, Bond S. Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial. Patient Educ Couns. 2003;51(3):277-84.

(15) Lockyer J, el-Guebaly N, Simpson E, Gromoff B, Toews J, Juschka B. Standardized patients as a measure of change in the ability of family physicians to detect and manage alcohol abuse. Academic medicine : journal of the Association of American Medical Colleges 1996.

(16) Rose HL, Miller PM, Nemeth LS, Jenkins RG, Nietert PJ, Wessell AM, et al. Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention. Addiction (Abingdon, England). 2008;103(8):1271-80.

(17) Adams A, Ockene JK, Wheeler EV, Hurley TG. Alcohol counseling: Physicians will do it. Journal of General Internal Medicine. 1998;13 (10):692-8

(18) Bonevski B, Sanson-Fisher RW, Campbell E, Carruthers A, Reid AL, Ireland M. Randomized controlled trial of a computer strategy to increase general practitioner preventive care. Preventive medicine 1999.

(19) Aalto, M., Hyvonen, S., & Seppa, K. (2006). Do primary care physicians' own AUDIT scores predict their use of brief alcohol intervention? A cross-sectional survey. Drug & Alcohol Dependence, 83 (2): 169-173.

(20) Aira, M., Kauhanen, J., Larivaara, P., & Rautio, P. (2003). Factors influencing inquiry about patients' alcohol consumption by primary health care physicians: qualitative semi-structured interview study. Family Practice, 20(3): 270-275.

(21) Kaner, E. F., Heather, N., McAvoy, B. R., Lock, C. A., & Gilvarry, E. (1999). Intervention for excessive alcohol consumption in primary health care: attitudes and practices of English general practitioners. Alcohol & Alcoholism, 34(4): 559-566.

(22) Deehan, A., Templeton, L., Taylor, C., Drummond, C., & Strang, J. (1998). Low detection rates, negative attitudes and the failure to meet the Health of the Nation alcohol targets: findings from a national survey of GPs in England and Wales. Drug & Alcohol Review, 17(3): 249-258.

(23) Heather, N. Dallolio, E. Hutchings, D. Kaner, E. White, M. (2004). Implementing routine screening and brief alcohol intervention in primary health care: A Delphi survey of expert opinion. Journal of Substance Use, 9(2): 68-85.

(24) Hutchings, D., Cassidy P, Dallolio E, Pearson P, Heather, N., & Kaner-Eileen, F. S. (2006). Implementing screening and brief alcohol interventions in primary care: views from both sides of the consultation. Primary Health Care Research and Development, 7: 1-9.

(25) Beich, A., Gannik, D., & Malterud, K (2002). Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ, 325(7369): 870.

Professionals' workload

Key finding

There is evidence that extending current practitioner workload is a potential barrier to implementing screening and brief intervention on a large scale, particularly if all young people and adults are screened as routine practice.

Commentary

There is evidence that extending current practitioner workload is a potential barrier to implementing screening and brief intervention on a large scale, particularly if all young people and adults are screened as routine practice (1-6).  There is evidence that the utilisation of non-clinical staff in implementation in order to delegate work and thus decrease the workload of clinicians is problematic (7, 8). There is evidence that formal integration of services, as well as skill mix changes and changes in medical record system can improve screening and brief intervention rate for primary care patients, however in most studies results were not significant (4, 9-18). A review showed that involving nurses and other professionals besides GPs in the screening policy, resulted in relatively more screened patients compared to involving solely GPs (19).

Supporting evidence

(1) Beich, A., Thorsen, T., & Rollnick, S. (2003). Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ, 327 (7414): 536-542

(2) Hutchings, D., Cassidy P, Dallolio E, Pearson P, Heather, N., & Kaner-Eileen, F. S. (2006). Implementing screening and brief alcohol interventions in primary care: views from both sides of the consultation. Primary Health Care Research and Development, 7: 1-9.

(3) Beich, A., Gannik, D., & Malterud, K. (2002). Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ, 325(7369): 870.

(4) Adams, A., Ockene, J. K., Wheller, E. V., & Hurley, T. G. (1998). Alcohol counseling: physicians will do it. Journal of General Internal Medicine. 13(10): 692-8.

(5) Aira, M., Kauhanen, J., Larivaara, P., & Rautio, P. (2003). Factors influencing inquiry about patients' alcohol consumption by primary health care physicians: qualitative semi-structured interview study. Family Practice, 20 (3): 270-275.

(6) Johansson, K., Akerlind, I., & Bendtsen, P. (2005). Under what circumstances are nurses willing to engage in brief alcohol interventions? A qualitative study from primary care in Sweden. Addictive Behaviors, 30(5): 1049-1053.

(7) Babor, T. E., Higgins-Biddle, J., Dauser, D., Higgins, P., & Burleson, J. A. (2005). Alcohol screening and brief intervention in primary care settings: implementation models and predictors. Journal of Studies on Alcohol, 66 (3): 361-368.

(8) Funk, M., Wutzke, S., Kaner, E., Anderson, P., Pas, L., McCormick, R., Gual, A., Barfod, S., & Saunders, J. (2005). A multi country controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: Findings of a WHO Collaborative Study. Journal of Studies on Alcohol, 66: 379-388.

(9) Brown RL, Saunders LA, Bobula JA, Mundt MP, Koch PE. Randomized-controlled trial of a telephone and mail intervention for alcohol use disorders: Three-month drinking outcomes. Alcoholism: Clinical and Experimental Research. 2007;31 (8):1372-9.

(10) Vinson DC, Devera-Sales A. Computer-generated written behavioral contracts with problem drinkers in primary medical care. Substance Abuse. 2000;21(4):215-22.

(11) Wilson A, McDonald P, Hayes L, Cooney J. Health promotion in the general practice consultation: a minute makes a difference. BMJ (Clinical research ed.) 1992.

(12) Ferrer RL, Mody-Bailey P, Jaén CR, Gott S, Araujo S. A medical assistant-based program to promote healthy behaviors in primary care. Annals of Family Medicine. 2009;7(6):504-12. doi:10.1370/afm.1059

(13) Oslin DW, Grantham S, Coakley E, Maxwell J, Miles K, Ware J, et al. PRISM-E: comparison of integrated care and enhanced specialty referral in managing at-risk alcohol use. Psychiatric services (Washington, D.C.) 2006.

(14) Oslin DW, Sayers S, Ross J, Kane V, Ten Have T, Conigliaro J, et al. Disease Management for Depression and At-Risk Drinking Via Telephone in an Older Population of Veterans. Psychosomatic Medicine. 2003;65 (6):931-7.

(15) Reiff-Hekking S, Ockene JK, Hurley TG, Reed GW. Brief physician and nurse practitioner-delivered counseling for high-risk drinking: Results at 12-month follow-up. Journal of General Internal Medicine. 2005;20 (1):7-13.

(16) Kypri K, Langley JD, Saunders JB, Cashell-Smith ML, Herbison P. Randomized controlled trial of web-based alcohol screening and brief intervention in primary care. Archives of Internal Medicine. 2008;168(5):530-6.

(17) Kypri K, McAnally HM. Randomized controlled trial of a web-based primary care intervention for multiple health risk behaviors. Preventive medicine. 2005;41 (3-4):761-6.

(18) Kypri K, Saunders JB, Williams SM, McGee RO, Langley JD, Cashell-Smith ML, et al. Web-based screening and brief intervention for hazardous drinking: A double-blind randomized controlled trial. Addiction (Abingdon, England). 2004;99 (11):1410-7.

(19) Keurhorst, M. et al. (Submitted). Determinants of successful implementation of screening and Advice for hazardous and harmful alcohol consumption in primary healthcare. A systematic review and meta-regression analysis of trials

Environments

Key finding

There is evidence that implementation of screening and brief intervention would be facilitated by use of environments where alcohol can discussed in a non-threatening way.

Commentary

There is evidence that implementation of screening and brief intervention would be facilitated by use of environments where alcohol can discussed in a non-threatening way. It seems that both practitioners and users regard clinics, registration sessions and routine consultations as opportunities for discussions of alcohol in a less-threatening environment and in a context that is related to the purpose of the visit, for example, lifestyle assessment or chronic condition monitoring (1-7). Applying multiple components of any implementation category was especially effective for increasing the application of brief interventions (8).

Factors affecting the primary prevention and health promotion implementation in primary care, could be divided into intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy. The institutional, community and public policy factors concerns the environments. Primary care is regarded as well-placed to implement primary prevention and health promotion, but workload, lack of time and referral resources, and the predominance of the biomedical model (which prioritizes disease treatment) hamper the implementation setting. The effectiveness of financial incentives and tools such as guidelines and alarms/reminders is conditioned by professionals’ attitudes to them. Community factors include patients’ social and cultural characteristics (religion, financial resources, etc.), local referral resources, mass-media messages and pharmaceutical industry campaigns, and the importance given to primary prevention and health promotion in the curriculum in university. Finally, policies affect the distribution of resources, thus affecting the implementation of primary prevention and health promotion (9).

Supporting evidence

(1) Johansson, K., Akerlind, I., & Bendtsen, P. (2005). Under what circumstances are nurses willing to engage in brief alcohol interventions? A qualitative study from primary care in Sweden. Addictive Behaviors, 30(5): 1049-1053.

(2) Heather, N. Dallolio, E. Hutchings, D. Kaner, E. White, M. (2004). Implementing routine screening and brief alcohol intervention in primary health care: A Delphi survey of expert opinion. Journal of Substance Use, 9(2): 68-85.

(3) Hutchings, D., Cassidy P, Dallolio E, Pearson P, Heather, N., & Kaner-Eileen, F. S. (2006). Implementing screening and brief alcohol interventions in primary care: views from both sides of the consultation. Primary Health Care Research and Development, 7: 1-9.

(4) Lock, C. A., & Kaner, E. F. S. (2004) Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice?. Family Practice, 21 (3): 270-275.

(5) Lock, C. A., Kaner, E., Lamont, S., & Bond, S. (2002). A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care. Journal of Advanced Nursing, 39(4): 333-342.

(6) Rapley, T., May, C., & Kaner, E. F. (2006). Still a difficult business? Negotiating alcohol-related problems in general practice consultations. Social Science & Medicine, 63(9): 2418-2428.

(7) McManus, S., Hipkins, J., Guthrie, E., & Creed, F. (2003). Implementing an effective intervention for problem drinkers on medical wards. General Hospital Psychiatry, 25: 332-337.

(8) Keurhorst, M. et al. (Submitted). Determinants of successful implementation of screening and Advice for hazardous and harmful alcohol consumption in primary healthcare. A systematic review and meta-regression analysis of trials

(9) Rubio-Valera M, Pons-Vigués M, Martínez-Andrés M, Moreno-Peral P, Berenguera A, Fernández A. (2014) Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography. PLoS One. 9(2):e89554

Relevant professionals

Key finding

There is some evidence that service users have preferences regarding the status of the person dealing with their alcohol issues.

Nurses have the potential to be the primary professional to deliver screening and brief interventions and reduce work load from physicians.

Commentary

There is some evidence that service users have preferences regarding the status of the person dealing with their alcohol issues. There is some evidence that users perceive counselling with alcohol specialists as stigmatising (1), although experts hold a different view (2). Some users perceive the nurse as having more time for discussing drinking, whereas other users are more likely to discuss alcohol-related issues with their doctor (3-5). Although former evidence was inconsistent about effectiveness of nurse-led interventions, a recent review showed that involving nurses and other professionals besides GPs in the screening policy, resulted in relatively more screened patients compared to involving solely GPs (8). However, various studies indicate there still are barriers with nurses to accept the substitution from physicians to nurses, as shown in this qualitative study amongst hospital nurses. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and referral to treatment for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features.

Supporting evidence

(1) Goldberg, H. I., Mullen, M., Ries, R. K., Psaty, B. M., & Ruch, B. P. (1991). Alcohol counseling in a general medicine clinic. A randomized controlled trial of strategies to improve referral and show rates. Medical Care, 29(7): JS49-JS56.

(2) Heather, N. Dallolio, E. Hutchings, D. Kaner, E. White, M. (2004). Implementing routine screening and brief alcohol intervention in primary health care: A Delphi survey of expert opinion. Journal of Substance Use, 9(2): 68-85.

(3) Hutchings, D., Cassidy P, Dallolio E, Pearson P, Heather, N., & Kaner-Eileen, F. S. (2006). Implementing screening and brief alcohol interventions in primary care: views from both sides of the consultation. Primary Health Care Research and Development, 7: 1-9.

(4) Lock, C. A., & Kaner, E. F. S. (2004) Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice?. Family Practice, 21 (3): 270-275.

(5) Lock, C. A., Kaner, E., Lamont, S., & Bond, S. (2002). A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care. Journal of Advanced Nursing, 39(4): 333-342.

(6) Lock CA, Kaner E, Heather N, Doughty J, Crawshaw A, McNamee P, Purdy S, Pearson P: Effectiveness of nurse-led brief alcohol intervention: a cluster randomized controlled trial. (2006). J Adv Nurs 54:426–439.

(7) Reiff-Hekking S, Ockene JK, Hurley TG, Reed GW: Brief physician and nurse practitioner-delivered counseling for high-risk drinking. Results at 12-month follow-up. (2005) J Gen Intern Med, 20:7–13.

(8) Keurhorst, M. et al. (Submitted). Determinants of successful implementation of screening and Advice for hazardous and harmful alcohol consumption in primary healthcare. A systematic review and meta-regression analysis of trials

(9) Broyles LM, Rodriguez KL, Kraemer KL, Sevick MA, Price PA, Gordon AJ. A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center. (2012). Addict Sci Clin Pract. 7(1):7

Service users

Key finding

There is some evidence that service users are generally positive about screening and intervention. There is also evidence for general under-activity in discussing drinking with service users.  

Commentary

There is some evidence that service users are generally positive about screening and intervention (1-3). There is also evidence for considerable under-activity in discussing drinking with service users (4-8), even in case of heavy drinking (2). Advice on drinking behaviour is provided less often than for other lifestyle behaviours, such as exercise, diet, and smoking, and less often than service users expect (6). Dutch primary care providers discuss the least time to alcohol discussion (0.28 minutes) and most time to dietary habits (1.29 minutes). However, GPs hardly ever applied MI in their consultations about patient’s lifestyle behaviour. PNs trained in MI did apply this technique, but to some extent only (9). Possible reasons include a reluctance to ask users about their drinking unless there are clear signs of risky drinking behaviour (10).  Some PC professionals discuss primary prevention and health promotion from a biomedical perspective. From this perspective, which gives little importance to social factors, the prevention of disease and the promotion of healthy lifestyles are omitted. On the other hand, the PC professionals that adopt a biopsychosocial perspective perceive PP&HP as an important part of their role and thus feel responsible for implementing these activities in practice. This is related to their position in terms of who should be considered responsible when implementing primary prevention and health promotion interventions. Professionals who think that primary prevention and health promotion activities should only be addressed to high-risk patients (thus with a higher probability of developing a disease) are more accepting of implementing them in PC (11).

Supporting evidence

(1) Miller, P. M., Thomas, S. E., & Mallin, R. (2006). Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol & Alcoholism, 41(3): 306-310.

(2) Hutchings, D., Cassidy P, Dallolio E, Pearson P, Heather, N., & Kaner-Eileen, F. S. (2006). Implementing screening and brief alcohol interventions in primary care: views from both sides of the consultation. Primary Health Care Research and Development, 7: 1-9.

(3) Aalto, M., Pekuri, P., & Seppa, K. (2002). Primary health care professionals' activity in intervening in patients' alcohol drinking: a patient perspective. Drug & Alcohol Dependence, 66(1): 39-43.

(4) Kaner, E. F., Heather, N., McAvoy, B. R., Lock, C. A., & Gilvarry, E. (1999). Intervention for excessive alcohol consumption in primary health care: attitudes and practices of English general practitioners. Alcohol & Alcoholism, 34(4): 559-566.

(5) Anderson, S., Eadie, D., MacKintosh, A., & Haw, S. (2001). Management of alcohol misuse in Scotland: the role of A&E nurses. Accident & Emergency Nursing, 9: 92-100.

(6) Johansson, K., Akerlind, I., & Bendtsen, P. (2005). Under what circumstances are nurses willing to engage in brief alcohol interventions? A qualitative study from primary care in Sweden. Addictive Behaviors, 30(5): 1049-1053.

(7) Aalto, M. & Seppa, K. (2004). Usefulness, length and content of alcohol-related discussions in primary health care: the exit poll survey. Alcohol and Alcoholism, 39(6): 532-535.

(8) Berner, M. M., Harter, M., Kriston, L., Lohmann, M., Ruf, D., Lorenz, G., & Mundle, G. (2007) Detection and management of alcohol use disorders in German primary care influenced by non-clinical factors. Alcohol & Alcoholism, 42(4): 308-316.

(9) Noordman, J., Koopmans, B., Korevaar, J.C., van der Weijden, T., and van Dulmen S. (2013) Exploring lifestyle counselling in routine primary care consultations: the professionals’ role. Family Practice, 30(3):332-40

(10) Aira, M., Kauhanen, J., Larivaara, P., & Rautio, P. (2003). Factors influencing inquiry about patients' alcohol consumption by primary health care physicians: qualitative semi-structured interview study. Family Practice, 20(3): 270-275.

(11) Rubio-Valera M, Pons-Vigués M, Martínez-Andrés M, Moreno-Peral P, Berenguera A, Fernández A. (2014) Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography. PLoS One. 9(2):e89554

Providers

Key finding

Provider attitudes, knowledge, skills and behaviour can influence the implementation of screening and brief intervention

Commentary

Provider attitudes, knowledge, skills and behaviour can influence the implementation of screening and brief intervention. This is the case for doctors (1, 2), receptionists (3) and nurses (2, 4, 5). Difficulties include working with multiple definitions of problematic drinking (1), lack of clear guidance (2), alcohol being an emotive issue, and misunderstanding of the implications of the potential protective effect of alcohol (4,5). The doctor's own relationship with alcohol can be a potential barrier to open discussion, or a facilitator to empathy (6,7). Users find that discussing drinking is facilitated by a good relationship with the health professional (8-10), whereas providers are concerned not to offend users in relation to discussing alcohol for fear of disturbing the therapeutic relationship (11). There are two factors that affect professionals’ motivation, the patient and the health system. Even when professionals have a positive attitude towards primary prevention and health promotion, if they feel the patient is not interested, or does not adhere to their recommendations, they feel frustration. PC professionals think that the health system expects them to conduct primary prevention and health promotion activities. This can also prove frustrating if the self-concept is low and/or the resources available are perceived to be scarce. This can affect motivation, changing the attitude towards PP&HP and setting up a vicious circle (12).

Supporting evidence

(1) Rapley, T., May, C., & Kaner, E. F. (2006). Still a difficult business? Negotiating alcohol-related problems in general practice consultations. Social Science & Medicine, 63(9): 2418-2428.

(2) Aalto, M., Pekuri, P., & Seppa, K. (2003). Obstacles to carrying out brief intervention for heavy drinkers in primary health care: a focus group study. Drug & Alcohol Review, 22 (2): 169-173.

(3) Lock, C. A., Kaner, E. F., Heather, N., Gilvarry, E., & McAvoy, B. R. (2000), Changes in receptionists' attitudes towards involvement in a general practice-based trial of screening and brief alcohol intervention. British Journal of General Practice, 50(451): 111-115.

(4) Lock, C. A., Kaner, E., Lamont, S., & Bond, S. (2002). A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care. Journal of Advanced Nursing, 39(4): 333-342.

(5) McManus, S., Hipkins, J., Guthrie, E., & Creed, F. (2003). Implementing an effective intervention for problem drinkers on medical wards. General Hospital Psychiatry, 25: 332-337.

(6) Kaner, E., Rapley, T., & May, C. (2006). Seeing through the glass darkly? A qualitative exploration of GPs' drinking and their alcohol intervention practices. Family Practice, 23(4): 481-487.

(7) Aalto, M., Hyvonen, S., & Seppa, K. (2006). Do primary care physicians' own AUDIT scores predict their use of brief alcohol intervention? A cross-sectional survey. Drug & Alcohol Dependence, 83 (2): 169-173.

(8) Lock, C. A., & Kaner, E. F. S. (2004) Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice?. Family Practice, 21 (3): 270-275.

(9) Hutchings, D., Cassidy P, Dallolio E, Pearson P, Heather, N., & Kaner-Eileen, F. S. (2006). Implementing screening and brief alcohol interventions in primary care: views from both sides of the consultation. Primary Health Care Research and Development, 7: 1-9.

(10) de Guzman, R., Leonard, N. R., Gwadz, M. V., Young, R., Ritchie, A. S., Arredondo, G., & Riedel, M. (2006). I thought there was no hope for me: a behavioral intervention for urban mothers with problem drinking. Qualitative Health Research, 16(9): 1252-1266.

(11) Beich, A., Gannik, D., & Malterud, K (2002). Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ, 325(7369): 870.

(12) Rubio-Valera M, Pons-Vigués M, Martínez-Andrés M, Moreno-Peral P, Berenguera A, Fernández A. (2014) Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography. PLoS One. 9(2):e89554

Service user population

Key finding

There is evidence that the consistency of provider implementation of screening and brief intervention can be influenced by particular aspects of the service user population.

Implementation strategies are likely to have no impact on alcohol consumption outcomes, although they significantly improved professionals’ screening and brief intervention delivery. To explain the gap between effect on alcohol consumption and screening and brief interventions, fidelity of delivery as well as required study power to detect effects on alcohol consumption should be investigated.

Commentary

There is evidence that the consistency of provider implementation of screening and brief intervention can be influenced by particular aspects of the service user population.  Although a systematic review found inconclusive evidence that socio-economic status affects the uptake of brief interventions (1), at least one study has found that unemployed individuals were more likely to receive brief intervention than those in employment (2). In terms of ethnicity, one US-based study found that Hispanic people were more likely to be approached by providers regarding their alcohol consumption (3). Users most likely to be given advice on drinking are males (4-7), who are also more likely to adhere to advice (8). One study found that Danish doctors  were reluctant to address drinking with young people as they felt that they would be grow out of drinking hazardously (9). Lifestyle discussions could enable self-determination in the process of lifestyle change but that certain conditions were required. Mutual interaction between the patient and the nurse that contributes to a sense of well-being in the patients was a necessary condition for the lifestyle discussion to be helpful. When the discussion resulted in a new way of thinking about lifestyle and when patient initiative was encouraged, the discussion could contribute to change. The patient's free will to make a lifestyle change and the nurse's sensitivity in the discussions created fertile soil for change (10). An interview study with problem alcohol users showed that Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the

issue. Nevertheless, patients felt that healthcare professionals should be more proactive in the management of problem alcohol use at a primary care level and that primary care can play an important role in their treatment (11).

A review showed that implementation strategies had a non-significant positive impact on patients’ alcohol consumption (standardized effect 0.07;95%-CI -0.02-0.16), although they effectively improved screening (standardized effect 0.53;95%-CI 0.28-0.78) and brief intervention delivery (standardized effect 0.64;95%-CI 0.27-1.02). To improve the impact on decreasing harmful alcohol consumption, patient, professional and organizational implementation strategies could be combined, e.g. changes to the setting/ site of service delivery and patient feedback (Kypri 2004). To explain the gap between effect on alcohol consumption and screening and brief interventions, fidelity of delivery as well as required study power to detect effects on alcohol consumption should be investigated (12).

Supporting evidence

(1) Littlejohn, C. (2006). Does socio-economic status influence the acceptability of, attendance for, and outcome of, screening and brief interventions for alcohol misuse: a review. Alcohol & Alcoholism, 41(5): 540-545.

(2)
Kaner, E. F., Heather, N., Brodie, J., Lock, C. A., & McAvoy, B. R. 2001, Patient and practitioner characteristics predict brief alcohol intervention in primary care, British Journal of General Practice, vol. 51, no. 471, pp. 822-827.

(3) Mukamal, K. J. (2007). Impact of race and ethnicity on counseling for alcohol consumption: a population-based, cross-sectional survey. Alcoholism: Clinical & Experimental Research, 31(3): 452-457.

(4) Lock, C. A., & Kaner, E. F. S. (2004) Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice?. Family Practice, 21 (3): 270-275.

(5) Johansson, K., Akerlind, I., & Bendtsen, P. (2005). Under what circumstances are nurses willing to engage in brief alcohol interventions? A qualitative study from primary care in Sweden. Addictive Behaviors, 30(5): 1049-1053.

(6) Berner, M. M., Harter, M., Kriston, L., Lohmann, M., Ruf, D., Lorenz, G., & Mundle, G. 2007, Detection and management of alcohol use disorders in German primary care influenced by non-clinical factors, Alcohol & Alcoholism, vol. 42, no. 4, pp. 308-316.

(7) Aalto, M., Pekuri, P., & Seppa, K. (2002). Primary health care professionals' activity in intervening in patients' alcohol drinking: a patient perspective. Drug & Alcohol Dependence, 66(1): 39-43.

(8) Aalto, M., Saksanen, R., Laine, P., Forsstrom, R., Raikaa, M., Kiviluoto, M., Seppa, K., & Sillanaukee, P. 2000, Brief intervention for female heavy drinkers in routine general practice: a 3-year randomized, controlled study, Alcoholism: Clinical & Experimental Research, vol. 24, no. 11, pp. 1680-1686.

(9) Beich, A., Gannik, D., & Malterud, K (2002). Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ, 325(7369): 870.

(10) Brobeck E, Odencrants S, Bergh H, Hildingh C. Patients' experiences of lifestyle discussions based on motivational interviewing: a qualitative study. (2014). BMC Nurs. 13:13.

(11) Catherine Anne Field, Jan Klimas, Joseph Barry, Gerard Bury, Eamon Keenan, Bobby P Smyth and Walter Cullen. Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment. (2013). BMC Family Practice, 14:98

(12) Keurhorst, M. et al. (Submitted). Determinants of successful implementation of screening and Advice for hazardous and harmful alcohol consumption in primary healthcare. A systematic review and meta-regression analysis of trials

Attitudes towards screening and intervention

Key finding

There is some evidence that service users are generally positive about screening and intervention.

Commentary

There is some evidence that service users are generally positive about screening and intervention (1-3), although this view is not always shared by providers (4, 5).  

A high proportion of patients attending primary care with unhealthy lifestyles (especially risky drinkers) do not perceive the need to change their habits, and about half the patients reported not having had any discussion on healthy lifestyles with their GPs. Only 30.5% of risky drinkers think they need to change, as opposed to 64% of smokers, 73.5% of patients with unhealthy eating habits and 73% with lack of physical activity. Risky drinkers reported that GPs initiated a discussion on alcohol consumption less often (42%) than on smoking (63%), eating habits (59%) or physical activity (55%). Seventy-five per cent, 66% and 63% of patients without hypertension, diabetes or hypercholesterolaemia, respectively, think blood pressure, blood sugar and serum cholesterol should be checked yearly (6). An interview study with problem alcohol users showed that Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the

issue. Nevertheless, patients felt that healthcare professionals should be more proactive in the management of problem alcohol use at a primary care level and that primary care can play an important role in their treatment (7).

A survey amongst hospital nurses in Australia showed that nurses held neutral to positive attitudes toward alcohol problems; however, 14.3% completely disagreed with the statement “I want to work with drinkers,” and 12.5% completely disagreed that they were likely to find working with people with alcohol problems rewarding. Attitudes to care were significantly influenced by age, personal drinking habits, and beliefs about whether patients can be helped, whether alcoholism is a character defect, and the relationship between alcoholism and social status. Negative attitudes towards patient care persist and are influenced by age, personal drinking habits, and beliefs about alcoholism (8). Another European survey showed that GPs who reported higher levels of education for alcohol and alcohol problems and GPs who felt more secure in managing patients with such problems reported managing a higher number of patients. GPs who reported that doctors tended to have a disease model of alcohol problems and those who felt that drinking was a personal rather than a medical responsibility reported managing a lower number of patients (9). In addition, reporting of a Dutch RCT showed that how important GPs thought it was to improve their care for problematic

alcohol consumption, and the GPs’ reported proportion of patients asked about alcohol consumption at baseline, contributed to the effect of the programme on therapeutic commitment. However, GPs’ role security did not change due to the implementation program (10).

Supporting evidence

(1) Miller, P. M., Thomas, S. E., & Mallin, R. (2006). Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol & Alcoholism, 41(3): 306-310.

(2) Hutchings, D., Cassidy P, Dallolio E, Pearson P, Heather, N., & Kaner-Eileen, F. S. (2006). Implementing screening and brief alcohol interventions in primary care: views from both sides of the consultation. Primary Health Care Research and Development, 7: 1-9.

(3) Aalto, M., Pekuri, P., & Seppa, K. (2002). Primary health care professionals' activity in intervening in patients' alcohol drinking: a patient perspective. Drug & Alcohol Dependence, 66(1): 39-43.

(4) Lock, C. A., Kaner, E., Lamont, S., & Bond, S. (2002). A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care. Journal of Advanced Nursing, 39(4): 333-342.

(5) Beich, A., Gannik, D., & Malterud, K (2002). Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ, 325(7369): 870.

(6) Brotons C, Bulc M, Sammut MR, Sheehan M, Manuel da Silva Martins C, Björkelund C, Drenthen AJ, Duhot D, Görpelioglui S, Jurgova E, Keinanen-Kiukkanniemi S, Kotányi P, Markou V, Moral I, Mortsiefer A, Pas L, Pichler I, Sghedoni D, Tataradze R, Thireos E, Valius L, Vuchak J, Collins C, Cornelis E, Ciurana R, Kloppe P, Mierzecki A, Nadaraia K, Godycki-Cwirko M. Attitudes toward preventive services and lifestyle: the views of primary care patients in Europe. the EUROPREVIEW patient study. (2012). Fam Pract. 29 Suppl 1:i168-i176

(7) (11) Catherine Anne Field, Jan Klimas, Joseph Barry, Gerard Bury, Eamon Keenan, Bobby P Smyth and Walter Cullen. Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment. (2013). BMC Family Practice, 14:98

(8) Crothers CE, Dorrian J. Determinants of Nurses' Attitudes toward the Care of Patients with Alcohol Problems. (2011). ISRN Nurs. 2011;821514

(9) Peter Anderson, Marcin Wojnar, Andrzej Jakubczyk, Antoni Gual, Lidia Segura, Hana Sovinova,  Ladislav Csemy, Eileen Kaner, Dorothy Newbury-Birch, Alessio Fornasin, Pierluigi Struzzo, Gaby Ronda, Ben van Steenkiste, Myrna Keurhorst, Miranda Laurant, Cristina Ribeiro, Frederico do Rosário, Isabel Alves, Marko Kolsek. Managing alcohol problems in general practice in Europe: results from the European ODHIN survey of general practitioners (accepted for publication).

(10) Myrna Keurhorst, Ivonne van Beurden, Peter Anderson, Maud Heinen, Reinier Akkermans, Michel Wensing and Miranda Laurant. GPs’ role security and therapeutic commitment in managing alcohol problems: a randomized controlled trial of a tailored improvement programme. (2014). BMC Family Practice, 15:70

Supportive alcohol policy measures

Price increase

Key finding

Alcohol price increases are the most cost-effective approach to reduce the harm done by alcohol.

Commentary

Tax increases represent the most cost-effective response to reduce the harm done by alcohol in countries with a high prevalence of heavy drinking. The effect of alcohol tax increases stands to be mitigated by illegal production, tax evasion and illegal trading. Reducing this unrecorded consumption via concerted tax enforcement strategies by law enforcement and excise officers is estimated to cost more than a tax increase but produces similar levels of effect. There are a number of parameters to consider when managing the price of alcohol.

First, it is the affordability of alcohol compared with other goods that matters. So, if price stays the same, but incomes go up, consumption goes up. Or, if price stays the same and the relative price of other goods in the shopping basket goes up, consumption goes up.

Second, specific or targeted taxes do not necessarily work. This is the case, for example, of the German alcopop tax which simply switched consumption of sprits-based mixed beverages to beer-based mixed beverages.

Third, alcohol prices differ between neighbouring jurisdictions, which does lead to consumers crossing nearby borders to purchase cheaper alcohol. But, this is much less of an issue than imagined. It is also important to note that some responses can make matters worse. In 2004, when Estonia joined the European Union, Finland, dropped alcohol taxes by one third, to act as a disincentive for consumers to buy cheaper alcohol from Estonia. However, the consequence was that sudden alcohol-caused deaths jumped immediately by 17% (government revenue fell by the same amount). And, it was the more deprived who were penalized, with the vast majority of the increase in deaths occurring amongst poorer as opposed to richer consumers. The damaging effects came from Finnish, not Estonian, alcohol.

Fourth, because of the addictive nature of alcohol, price elasticities of alcoholic beverages may not be symmetrical. In other words, a decrease of a certain magnitude in alcohol prices may have a greater impact on alcohol consumption than the same magnitude of price increase realized afterwards. This is illustrated by the above Finnish example. Following the 33% reduction in excise duty rates in 2004, total alcohol consumption per capita was 12% higher in 2005 than in 2003. In 2008 and 2009, alcohol excise duty rates were increased three times, by an average of about 10% each time. Between 2007 and 2010, total alcohol consumption fell by 3%. Thus, consumption went up by 12% when taxes fell by 33%, but went down by only 3% when taxes went up about 30%, an example of asymmetry in elasticities.

Fifth, alcohol is not normally taxed per gram, which would be a rational way to reflect that, for health, it is the number of grams of alcohol that matter; in some countries, alcohol is not subject to an excise tax at all. A volumetric tax which taxes alcohol equally across beverage types is less distortive of consumer preferences and more efficient at reducing consumption than where taxes are charged at varying amounts per litre of pure alcohol depending on beverage type.  

And, finally, sixth, a tax increase is not normally followed by an equivalent price increase, with producers and retailers responding in different ways. Sometimes the price goes up more than would be expected. Other times, and more commonly, the price goes up less than expected, meaning that producers and retailers have the capacity to absorb some of the price that would have resulted from a tax increase.

One way to get round some of these issues is to set a minimum price per gram of alcohol sold. This option also has many other advantages, in that, even more than tax increases, which also do the same, introducing a minimum price per gram of alcohol sold targets heavy drinking occasions and heavy drinkers, much more so than lighter drinkers, and appears minimally regressive. Minimum alcohol prices in British Columbia, Canada, have been adjusted intermittently over the years 1989-2010. Time series and longitudinal models of aggregate alcohol consumption with price and other economic data as independent variables found that a 10% increase in the minimum price of an alcoholic beverage reduced its consumption relative to other beverages by 16.1%. Time series estimates indicated that a 10% increase in minimum prices reduced consumption of spirits and liqueurs by 6.8%, wine by 8.9%, alcoholic sodas and ciders by 13.9%, beer by 1.5%, and all alcoholic drinks by 3.4 %. A 10% increase in minimum prices was also found to reduce wholly alcohol attributable deaths by 32%.

Supporting evidence

Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009; 373: 2234–46.

Anderson, P., Møller, L. & Galea, G. (eds.) Alcohol in the European Union. Consumption, harm and policy approaches. Copenhagen, Denmark: World Health Organization Regional Office for Europe.

Anderson, P., Amaral-Sabadini, M. B., Baumberg, B., Jarl, J., & Stuckler, D. (2011). Communicating alcohol narratives: Creating a healthier relation with alcohol. Journal of Health Communication, 16(S2), 27–36.

Anderson, P., Casswell, S., Parry, C. & Rehm, J. (2013). Alcohol. In Eds. Ollila, E & Pena, S. Health in All Policies. Brussels, European Health Observatory.

Anderson, P., Suhrcke, M. & Brookes, C. An overview of the market for alcohol beverages of potentially particular appeal to minors. London, HAPI, 2012a.

Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: No ordinary commodity (Second Edition). Oxford, Oxford University Press, 2010.

Österberg, E. Pricing of alcohol. In eds. Anderson, P., Møller, L. & Galea, G. Alcohol in the European Union. Copenhagen, Denmark: World Health Organization, 2012.

Purshouse, R. C. et al. (2010) “Estimated Effect of Alcohol Pricing Policies on Health and Health Economic Outcomes in England: An Epidemiological Model”, Lancet, Vol. 375, pp. 1355–1364.

Rabinovich L, Brutscher P-B, Vries H, Tiessen J, Clift J, Reding A. The affordability of alcoholic beverages in the European - Union Understanding the link between alcohol affordability, consumption and harms. Technical Report. RAND Corporation, 2009.

Stockwell, T., Auld, C., Zhao, J. & Maryin, G. Does minimum pricing reduce alcohol consumption? The experience of a Canadian province.Addiction, 2012. doi: 10.1111/j.1360-0443.2011.03763.x

Zhao, J., Stockwell, T., Martin, G., Macdonald, S., Vallance, K., Treno, A., Ponicki, W.R., Tu, T. & Buxton, J. (2013). The Relationship between Minimum Alcohol Prices, Outlet Densities and Alcohol Attributable Deaths in British Columbia, 2002 to 2009. Addiction 10.1111/add.12139.

Limits on availability

Key finding

Limiting the availability of alcohol reduces the harm done by alcohol.

Commentary

Increasing the availability of alcohol sales times by two or more hours increases alcohol-related harm. With the international trend towards increased bar opening hours, few studies have examined the impacts of reduced alcohol service hours in bars. However, in Newcastle, Australia, pub closing times were restricted in 2008 following police and public complaints about violence, disorderly behaviour and property damage related to intoxication. The restrictions led to a reduction in recorded assaults of 37%. Greater alcohol outlet density is associated with increased alcohol consumption and harms, including injury, violence, crime and medical harm. One form of alcohol sales regulation used in many countries is for the government to monopolize ownership of one or more types of retail outlet. In addition to limiting outlet density and the hours and days of sale, such monopolies remove the private profit motive for increasing sales. There is substantial evidence that such monopolies reduce alcohol consumption and alcohol-related harm.

Restricting availability increase the time costs and inconvenienced in obtaining alcohol, and there are interactions between price and availability measures, with price elasticities tending to be higher with less restrictions on availability, because price then forms a greater component of the cost.

Supporting evidence

Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009; 373: 2234–46.

Anderson, P., Møller, L. & Galea, G. (eds.) Alcohol in the European Union. Consumption, harm and policy approaches. Copenhagen, Denmark: World Health Organization Regional Office for Europe.

Anderson, P., Amaral-Sabadini, M. B., Baumberg, B., Jarl, J., & Stuckler, D. (2011b). Communicating alcohol narratives: Creating a healthier relation with alcohol. Journal of Health Communication, 16(S2), 27–36.

Anderson, P., Casswell, S., Parry, C. & Rehm, J. (2013). Alcohol. In Eds. Ollila, E & Pena, S. Health in All Policies. Brussels, European Health Observatory.

Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: No ordinary commodity (Second Edition). Oxford, Oxford University Press, 2010.

Bryden A,Roberts B,McKee M et al. (2012).A systematic review of the influence on alcohol use of community level availability and marketing of alcohol. Health and Place, 18(2):349357.

Kypri K, Jones C, McElduff P et al. (2010). Effects of restricting pub closing times on night-time assaults in an Australian city. Addiction, 106:303–310.

Österberg, E. Availability of alcohol. In eds. Anderson, P., Møller, L. & Galea, G. Alcohol in the European Union. Copenhagen, Denmark: World Health Organization, 2012.

Zhao, J., Stockwell, T., Martin, G., Macdonald, S., Vallance, K., Treno, A., Ponicki, W.R., Tu, T. & Buxton, J. (2013). The Relationship between Minimum Alcohol Prices, Outlet Densities and Alcohol Attributable Deaths in British Columbia, 2002 to 2009. Addiction 10.1111/add.12139.

Limits on commercial communications

Key finding

Limiting commercial communications of alcohol reduces the harm done by alcohol.

Commentary

A meta-analysis of 132 econometric studies found a small but significant positive association between alcohol advertising and alcohol consumption, although only for spirits advertising. Looking at alcohol advertising expenditure data across the United States, when controlling for alcohol price, income and a number of socio-demographic variables, advertising expenditure has an independent yet modest effect on the monthly number of adolescents drinking and binge-drinking. It has been estimated that a 28% reduction in alcohol advertising would reduce the monthly share of adolescent drinkers from 25% to between 24% and 21%. For binge-drinking, the reduction would be from 12% to between 11% and 8%. Controlling for price, income and minimum legal drinking age across the United States, it has been found that, although total alcohol consumption was negatively related to a ban on the advertising of spirit prices (the ban led to less consumption, coefficient -0.009), it was positively related to a ban on billboards (which accounted for only 8% of total alcohol advertising) which led to more consumption, coefficient 0.054. In a more recent study, the effect of partial bans was reported not to have affected alcohol consumption in 17 countries over 26 years. There are methodological difficulties with these econometric studies primarily due to alcohol advertising expenditure being used as approximate measures of the effectiveness of alcohol marketing.

In contrast, evidence from longitudinal observational studies shows that commercial communications, particularly through social media and electronic communication outlets, encourages non-drinkers to start drinking and existing drinkers to drink more. Even simply watching a one hour movie with a greater number of drinking scenes, or viewing simple advertisements can double the amount drunk over the hour’s viewing period. In many jurisdictions, much store is put on self-regulation of commercial communications and withdrawal of communications that are found to breach self-regulatory codes. However, these approaches are irrelevant, since extensive evidence shows that withdrawn commercial communications simply live on, accessible to all, in social media, which are, in any case, heavily financed by global alcohol producers.

Supporting evidence

Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009; 373: 2234–46.

Anderson, P., Møller, L. & Galea, G. (eds.) Alcohol in the European Union. Consumption, harm and policy approaches. Copenhagen, Denmark: World Health Organization Regional Office for Europe.

Anderson, P., Amaral-Sabadini, M. B., Baumberg, B., Jarl, J., & Stuckler, D. (2011b). Communicating alcohol narratives: Creating a healthier relation with alcohol. Journal of Health Communication, 16(S2), 27–36.

Anderson, P., Casswell, S., Parry, C. & Rehm, J. (2013). Alcohol. In Eds. Ollila, E & Pena, S. Health in All Policies. Brussels, European Health Observatory.

Anderson, P., Suhrcke, M. & Brookes, C. An overview of the market for alcohol beverages of potentially particular appeal to minors. London, HAPI, 2012.

Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: No ordinary commodity (Second Edition). Oxford, Oxford University Press, 2010.

deBruijn, A. The impact of alcohol marketing. In eds. Anderson, P., Møller, L. & Galea, G. Alcohol in the European Union. Copenhagen, Denmark: World Health Organization, 2012.

Gallet CA (2007). The demand for alcohol: a meta-analysis of elasticities. Australian Journal of Agricultural and Resource Economics, 51(2):121–135.

Nelson JP (2003). Advertising bans, monopoly and alcohol demand: testing for substitution effects using state panel data. Review of Industrial Organization, 22:1–25.

Nelson JP (2010). Alcohol advertising bans, consumption, and control policies in seventeen OECD countries, 1975–2000. Applied Economics, 42:803–823.

Saffer H, Dave D (2006). Alcohol advertising and alcohol consumption by adolescents. Health Economics, 15(6):617–637.

Assessment of delivery of BIs

ODHIN assessment tool

Key finding

The ODHIN assessment tool is effective as a comprehensive standard format to be used for the evaluation of the availability of services devoted to the management of HHAC at the country/region at level.

Commentary

The ODHIN assessment tool [1] was used by scientists and experts from 23 countries across Europe who were asked about 7 key areas for the project: presence of a country coalition partnership; community action media and education; health care infrastructures; support for treatment provision; intervention and treatment; health care providers; and health care users.

The experience of the ODHIN project gave the opportunity to look at the assessment tool as a feasible way to document the current situation across Europe, contributing to identifying existing gaps or areas that need further work or strengthening at the country/regional level.

Supporting evidence

[1] Gandin, C. & Scafato, E. (2013). ODHIN Assessment Tool – Report. A description of the available services for the management of hazardous and harmful alcohol consumption. Deliverable 6.1, Work Package 6. ODHIN Project, financed by the European Commission’s – Seventh Framework Programme.


Presence of a country coalition or partnership

Key finding

In 2012, most of the countries (78.3%) have a country and/or regional coalition for the management of HHAC.

Commentary

In 2012, most of the countries have a country and/or regional coalition for the management of HHAC. Specifically, 17 (73.9%) have a country-wide coalition, and 10 (43.5%) a region-wide formal or informal coalition or partnership that deals with the management HHAC. Only five countries of those studied (Poland, Malta, Cyprus, Croatia and Greece) have no country/regional coalition in this sense.

Supporting evidence

[1] Gandin, C. & Scafato, E. (2013). ODHIN Assessment Tool – Report. A description of the available services for the management of hazardous and harmful alcohol consumption. Deliverable 6.1, Work Package 6. ODHIN Project, financed by the European Commission’s – Seventh Framework Programme.

Community action, media and education

Key finding

Media education campaigns on alcohol consumption, are, in general, not widely implemented or not reported in some countries.

Commentary

The results show that the most common education campaigns are reported on the website (15 out of 23 countries, 65.2%) followed by newspaper / magazines (47.8%) and radio (39.1%). Among the media, billboards and TV are the least used for community action and education campaigns about HHAC. Where available, campaigns are usually fully publicly funded. A general predominance of media focused on “why reduce” rather than “how to reduce” is also remarkable.

Supporting evidence

[1] Gandin, C. & Scafato, E. (2013). ODHIN Assessment Tool – Report. A description of the available services for the management of hazardous and harmful alcohol consumption. Deliverable 6.1, Work Package 6. ODHIN Project, financed by the European Commission’s – Seventh Framework Programme.

Health care infrastructures

Key finding

In most countries, the integration of the management of HHAC into the health care system is quite low with a large amount of variation between countries.

Commentary

The availability of governmental quality structures for managing HHAC is around 65% of the 23 countries. There is a lack of formal education on managing on HHAC for health care professionals (especially for pharmacists and dentists). Moreover, in 2012 an official written policy on managing HHAC from the Government or Ministry of Health is reported in 82.6% of the countries, mostly as a part of a more general alcohol policy strategy. In the countries where such a policy exists, an intensive support for managing alcohol dependence in specialized treatment facilities is included in all countries, a strategy on training for health professionals in 73.7%, a strategy to support interventions in primary care in 68.4%, while a national funded research strategy is only included under half of the policies. Finally, in most of the countries (82.6%) there is government funding for services for the management of HHAC.

Supporting evidence

[1] Gandin, C. & Scafato, E. (2013). ODHIN Assessment Tool – Report. A description of the available services for the management of hazardous and harmful alcohol consumption. Deliverable 6.1, Work Package 6. ODHIN Project, financed by the European Commission’s – Seventh Framework Programme.

Support for treatment provisions

Key finding

There is a huge variation between countries in terms of support for treatment provision against HHAC.

Commentary

In 56.5% of the countries (13 out of 23) screening instruments to identify at risk drinkers are considered available, and most of the countries (69.6%) have already developed multidisciplinary guidelines. However there is still a great lack of studies on their adherence and implementation. In terms of reimbursements a small proportion of addition specialists (41.2%) are paid for managing HHAC but the most common practice is reimbursement as a part of their normal salary.

Supporting evidence

[1] Gandin, C. & Scafato, E. (2013). ODHIN Assessment Tool – Report. A description of the available services for the management of hazardous and harmful alcohol consumption. Deliverable 6.1, Work Package 6. ODHIN Project, financed by the European Commission’s – Seventh Framework Programme.

Intervention and treatment

Key finding

Help for patients with HHAC is not considered easily accessible or available in primary health care services.

Commentary

Help for patients with HHAC is most usually accessible through addiction services followed by specialist clinics, general/family practice, hospital clinics and, to a lesser extent, in pharmacies.

Supporting evidence

[1] Gandin, C. & Scafato, E. (2013). ODHIN Assessment Tool – Report. A description of the available services for the management of hazardous and harmful alcohol consumption. Deliverable 6.1, Work Package 6. ODHIN Project, financed by the European Commission’s – Seventh Framework Programme.

Health care providers

Key finding

Participants claimed that addiction specialists, followed by psychiatrists, consider giving advice for HHAC as part of their routine clinical practice, but not pharmacists and dentists.

Commentary

Many studies on treatment provision in primary care were cited to support the participants’ opinions: surveys or publications on patients screened for alcohol consumption (in 73.9% of the countries); studies on the use of the AUDIT questionnaire (52.4%); on the attitudes of health care providers to managing HHAC (50%); and on patients with HHAC who are given advice (50%). There is also research into how to increase the involvement of health care providers in managing HHAC (45%), on the effectiveness of interventions for HHAC (36.8%) and investigating whether and how practice protocols and guidelines are followed (27.8%). Few studies, survey or publications have been carried out on advice meets quality criteria (15.8%) and on cost-effectiveness of interventions for HHAC (10.5%).

Supporting evidence

[1] Gandin, C. & Scafato, E. (2013). ODHIN Assessment Tool – Report. A description of the available services for the management of hazardous and harmful alcohol consumption. Deliverable 6.1, Work Package 6. ODHIN Project, financed by the European Commission’s – Seventh Framework Programme.

Health care users

Key finding

In terms of people’s knowledge on the extent in which HHAC can be dangerous to their health, studies, surveys or publications are referred to in 38.1% of the countries.

Commentary

Studies on people’s knowledge about effective methods to reduce HHAC are not available.

Supporting evidence

[1] Gandin, C. & Scafato, E. (2013). ODHIN Assessment Tool – Report. A description of the available services for the management of hazardous and harmful alcohol consumption. Deliverable 6.1, Work Package 6. ODHIN Project, financed by the European Commission’s – Seventh Framework Programme.

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