Cochrane for Clinicians

Putting Evidence into Practice

Effectiveness of Brief Alcohol Interventions in Primary Care

Am Fam Physician. 2009 Mar 1;79(5):370-371.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 367.

Clinical Scenario

A 45-year-old man has a follow-up on rib fractures from a motorcycle crash that occurred while he was intoxicated.

CLINICAL QUESTION

What is the effectiveness of brief alcohol interventions in primary care populations?

EVIDENCE-BASED ANSWER

For men who engage in excessive or hazardous drinking and present to their primary care physician for issues not specifically related to alcohol treatment, an intervention of one to four sessions administered by a physician, nurse, or psychologist is effective in reducing weekly alcohol consumption one year later. It is also effective in reducing emergency department visits and alcohol-related injuries. The effect was not demonstrated in women. Longer counseling did not significantly improve the effect.

Cochrane Abstract

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

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

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

Selection Criteria: Criteria included randomized controlled trials (RCTs) of patients presenting to primary care not specifically for alcohol treatment; brief intervention of up to four sessions.

Data Collection and Analysis:: Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, subgroup, sensitivity analyses, and metaregression were conducted.

Main Results: The meta-analysis included 21 RCTs (n = 7,286), showing that participants receiving brief intervention reduced their alcohol consumption compared with the control group (mean difference: −41 grams per week; 95% confidence interval [CI], −57 to −25 grams per week), although there was substantial heterogeneity between trials (intervention implementation [I2] = 52 percent). Subgroup analysis of eight studies (n = 2,307) confirmed the benefit of brief intervention in men (mean difference = −57 grams per week; 95% CI, −89 to −25 grams per week; I2 = 56 percent), but not in women (mean difference = −10 grams per week; 95% CI, −48 to 29 grams per week; I2 = 45 percent). Metaregression showed a nonsignificant trend of an increased reduction in alcohol consumption of 1.1 (95% CI, −0.05 to 2.2 grams per week; P = .06) for each extra minute of treatment exposure, but no relationship between the reduction in alcohol consumption and the efficacy score of the trial. When compared with brief intervention, extended intervention was associated with a nonsignificantly greater reduction in alcohol consumption (mean difference = −28; 95% CI, −62 to 6 grams per week; I2 = 0 percent).

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


These summaries have been derived from Cochrane reviews published in the Cochrane Database of SystematicReviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the originalreviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minorediting changes have been made to the text (http://www.cochrane.org).

PRACTICE POINTERS

The World Health Organization estimates that alcohol causes nearly 1.8 million deaths each year, with 76.3 million persons worldwide having diagnosable alcohol use disorders.1 In the United States, excessive alcohol use is the third-leading lifestyle-related cause of death, responsible for up to 79,000 deaths annually. According to the Centers for Disease Control and Prevention, nearly 5 percent of the U.S. population drinks heavily, whereas up to 15 percent engage in binge drinking.2 Most of the harm from alcohol comes from those who are not alcohol dependent, but who engage in excessive or hazardous drinking.3 Therefore, interventions to reduce alcohol use have the potential to save lives and reduce alcohol-related morbidity.

Most of the studies evaluated in this Cochrane review were conducted in primary care settings. Screening methods for alcohol use included general health questionnaires and established alcohol-use screening tools for primary care, such as the CAGE (cut down, annoyed, guilty, eye-opener) questionnaire,4 Alcohol Use Disorders Identification Test,5,6 or Michigan Alcoholism Screening Test.7 Brief interventions to address alcohol use included motivational interviewing, cognitive behavior therapy, self-completed action plans, educational leaflets, requests to keep drinking diaries, and home exercises. Some interventions took place in a single session, whereas others took up to four sessions, with session duration ranging from five to 50 minutes.

Compared with the control group, patients receiving brief alcohol-use interventions reduced weekly alcohol consumption by about 41 grams of alcohol, or three drinks. In the United States, 14 grams of alcohol is considered a standard drink, equivalent to: 12 oz of beer; 8 to 9 oz of malt liquor; 5 oz of wine; 2 to 3 oz of liqueur; or 1.5 oz of brandy, gin, vodka, or whiskey.6

Brief interventions led to greater reductions in weekly alcohol intake among men (who averaged a reduction in alcohol of four drinks per week compared with the control group, and a six-drink reduction per week overall) than among women (who, compared with the control group, reduced weekly alcohol consumption by less than one drink). However, all the trials included in the review found that brief interventions reduced the percentage of persons drinking heavily, and reduced the percentage of binge drinkers. Brief interventions also led to a slight reduction in emergency department visits and a 47 percent reduction in injuries.

Brief alcohol-reduction interventions are one way family physicians can help patients identify and begin to change a significant health-risk behavior. Because benefit has been demonstrated from interventions as short as one hour or less, it is not unreasonable to incorporate alcohol screening and intervention into routine clinical practice. Persons with alcohol dependence may require more intensive treatment.

Screening tools to detect risky alcohol use are available online (see accompanying table). The National Institute on Alcohol Abuse and Alcoholism also has educational materials on brief alcohol interventions and clinical tools to document alcohol screening, counseling, and follow-up.6

Table.

Online Resources on Alcohol Abuse Prevention

American Academy of Family Physicians http://www.aafp.org/about/policies/all/substance-abuse.html

National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/guide.htm

Centers for Disease Control and Prevention http://www.cdc.gov/alcohol/

Alcohol-Related Disease Impact System http://apps.nccd.cdc.gov/ardi/Homepage.aspx

Table.   Online Resources on Alcohol Abuse Prevention

View Table

Table.

Online Resources on Alcohol Abuse Prevention

American Academy of Family Physicians http://www.aafp.org/about/policies/all/substance-abuse.html

National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/guide.htm

Centers for Disease Control and Prevention http://www.cdc.gov/alcohol/

Alcohol-Related Disease Impact System http://apps.nccd.cdc.gov/ardi/Homepage.aspx

Address correspondence to William E. Cayley Jr., MD, at bcayley@yahoo.com. Reprints are not available from the author.

Author disclosure: Nothing to disclose.

REFERENCES

1. World Health Organization. Global status report on alcohol 2004. http://www.who.int/substance_abuse/publications/global_status_report_2004_overview.pdf. Accessed September 30, 2008.

2. Centers for Disease Control and Prevention. Alcohol and public health. http://www.cdc.gov/alcohol/. Accessed September 30, 2008.

3. Kaner EF, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007;(2):CD004148.

4. Buchsbaum DG, Buchanan RG, Centor RM, Schnoll SH, Lawton MJ. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Intern Med. 1991;115(10):774–777.

5. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. 2nd ed. Geneva, Switzerland: World Health Organization; 2001. http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf. Accessed September 30, 2008.

6. National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide and related professional support resources. http://www.niaaa.nih.gov/Publications/EducationTraining Materials/guide.htm. Accessed September 30, 2008.

7. Selzer ML. The Michigan alcoholism screening test: the quest for a new diagnostic instrument. Am J Psychiatry. 1971;127(12):1653–1658.

The Cochrane Abstract is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Dr. Cayley presents a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a critique of the review. The practice recommendations in this activity are available at http://www.cochrane.org/reviews/en/ab004148.html.

The series coordinator for AFP is Clarissa Kripke, MD, Department of Family and Community Medicine, University of California, San Francisco.


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