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

doi:10.1111/j.1465-3362.2010.00217.x

Drug Alcohol Rev. Author manuscript; available in PMC 2011 November 1.

Published in final edited form as:

Drug Alcohol Rev. 2010 November; 29(6): 631–640.

doi: 10.1111/j.1465-3362.2010.00217.x

PMCID: PMC2966031

NIHMSID: NIHMS219252

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

RICHARD SAITZ, MD, MPH, FACP, FASAM

RICHARD SAITZ, Boston University Schools of Medicine and Public Health and Boston Medical Center, Boston, MA, USA;

Correspondence to Richard Saitz, MD, MPH, Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA. Tel: 617-414-7744; Fax: 617-414-4676; Email: rsaitz/at/bu.edu

Richard Saitz MD, MPH, FACP, FASAM, Professor of Medicine and Epidemiology, Boston University Schools of Medicine and Public Health and Boston Medical Center, Boston, MA, USA.

See other articles in PMC that cite the published article.

Abstract

Issues

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

Approach

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

Key Findings

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

Conclusion and Implications

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

Keywords: alcohol, alcohol dependence, primary care, brief intervention, systematic review

Background

Alcohol brief intervention (BI) has proven efficacy in primary-care patients with non-dependent unhealthy alcohol use identified by screening [1–4]. Systematic reviews of controlled trials have found a reduction in alcohol consumption of 38 g per week [2] and a 12% reduction in the proportion of patients drinking risky amounts[1] among patients receiving BI compared with those receiving no intervention. However, screening identifies people with the range of unhealthy alcohol use, from risky use without consequences through dependence, and the efficacy of BI for patients with very heavy use or dependence, particularly those identified by screening, has not been established. This observation is important, since 20% of primary-care patients with unhealthy alcohol use identified by screening have dependence [5].

Furthermore, readiness to change and effectiveness of treatment should not be assumed to be the same for people seeking help versus those identified by screening. People with non-dependent unhealthy use may simply be unaware of the consumption amounts that risk health consequences or may have experienced few, if any, consequences related to drinking. As a result, they often are not seeking help or advice. In that circumstance, and without loss of control over their drinking, one would expect them to respond to brief advice from their physician, whom they see for preventive and primary care, when it is offered appropriately. On the other hand, people with dependence who seek help often do benefit from treatment, including BI [6]. In such cases, the patient has already taken the first steps towards change, unlike the patient identified by screening. Although patients with dependence often report high readiness to change [7], by definition (i.e. dependence criteria), they have great difficulty doing so. Those identified through screening are not actively seeking help and, therefore, are less likely to be amenable to change. Thus, the literature on efficacy of treatment for people with alcohol dependence may not apply to those identified by screening. The widespread and continued existence of (not brief) specialty care for alcoholism confirms that experts have not concluded that BI is sufficient treatment for dependence. Furthermore, some believe that severity of unhealthy use is an explanation for negative studies of alcohol BI [8].

In clinical practice, the severity of alcohol use is not known until after screening, and clinicians need something efficacious to offer all patients identified as having unhealthy use, including those with greater severity or with dependence. The solution has been to perform BI among patients with dependence with a goal of motivating change, including referral and treatment. Yet it remains unknown whether BI in such patients leads to a decrease in use or alcohol-related consequences or to linkage with treatment. This systematic review of randomised controlled trials (RCTs) sought to find evidence to determine whether BI among patients identified by screening in primary-care settings as having alcohol dependence decreases consumption or alcohol-related consequences or increases initiation of, or engagement in, further alcohol treatment.

Methods

Inclusion criteria

This analysis included randomised controlled trials published in English in the peer-reviewed literature through September 2009 that compared primary-care patients with unhealthy alcohol use identified by screening who received BI with patients who received no intervention. Brief interventions were conducted in-person (not by telephone, mail, or computer). Each could include up to four follow-up sessions. The goal of the BI could be to reduce drinking and/or alcohol consequences or to provide a referral to additional care.

Exclusion criteria

Studies conducted among hospital inpatients or in emergency departments, trauma centers, or other settings not considered primary care per the US Institute of Medicine definition (i.e. integrated, accessible health care by clinicians who are accountable for addressing a large majority of personal health-care needs, who develop a sustained partnership with patients, and who practice in the context of family and community [9]) were excluded, as were studies including patients with comorbid conditions (e.g. gastrointestinal disease, hypertension, or pregnancy). Studies that compared BI to another active treatment (versus usual care or no intervention) were also excluded, as were studies among patients not identified by screening, since motivation for change and severity of use can be substantially different in such patients. Additional exclusions were duplicate reports of results from the same study and studies with methodological flaws as defined in Whitlock et al. [4]. They used internal-validity [10] and quality [11] criteria to exclude trials of poor quality. Major quality problems were non-random assignment, non-comparable baseline conditions, attrition greater than 30%, inadequate or unavailable consumption data, or lack of data on alcohol-related consequences or treatment linkage outcomes) [4].

Search strategy

Studies were selected from two recent exhaustive, high-quality systematic reviews by Kaner et al. [3] and Whitlock et al. [4], which identified RCTs of alcohol BI among primary care patients through 2006. References from six other systematic reviews of alcohol BI in primary care were examined to identify additional studies [1,2,12–15]. Other systematic reviews may exist but were not identified and, therefore, were not included in this review. Finally, an electronic literature search was conducted to identify RCTs published from 2006 through September 2009 using an inclusive search strategy that combined relevant keywords and medical subject headings (MeSH) across five relevant and comprehensive online databases (Appendix 1).

Study selection

Thirty-three studies were identified by Whitlock et al. [4] and Kaner et al [3]. Of these, 19 were excluded from this analysis, the reasons for which are listed in Appendix 2. The remaining 14 studies [16–29] were included in this analysis. Examination of the six additional systematic reviews [1,2,12–15] identified one RCT [30] meeting inclusion criteria (found in Bertholet et al. [2]), which was also included in this analysis.

The electronic search of Medline and the Cochrane Database of Systematic Reviews identified 227 potential articles published between 2006 and September 2009, of which eight were studies of alcohol BI. Seven of the eight studies did not meet inclusion criteria. The reasons for exclusion are listed in Appendix 2. Searches of four additional relevant databases yielded a number of potential additions but no additional studies meeting inclusion criteria. Thus, one study [31] was included from this search. Combined with the RCTs identified in the previously published systematic reviews, a total of 16 studies (N=6839 patients) were included in this analysis (Table 1).

Table 1

Summary of alcohol screening and brief intervention trials included in the systematic review

Findings

Of the 16 RCTs meeting inclusion criteria, 14 excluded some or all subjects with very heavy alcohol use or dependence, the definitions of which were specific to each study (Table 2). Only two studies included patients with dependence or did not exclude people based on an upper limit of consumption (Table 3). In the study by Burge et al. [30], 10–15 minute BI by resident family physicians was compared with six weekly 90-minute educational sessions, receipt of both interventions, or receipt of no intervention among 175 Mexican Americans (75% of whom were men, 35% of whom had dependence, and 65% of whom had abuse). Follow-up occurred over 18 months. No difference was found between groups on drinks per week or Addiction Severity Index (ASI) alcohol scores. An interaction between BI and ASI alcohol score was not significant, suggesting a similar lack of response to intervention across the range of severity. The ASI family scale score improved among all subjects at 12 months, but at 18 months, BI was associated with a loss of this initial improvement among women. All groups showed improvement in the ASI medical score at 12 months, but only those in either intervention group continued to improve at 18 months, while those who received both interventions or no intervention did not. There were no group outcome differences in employment, legal-problem severity, psychiatric severity, or laboratory test results (mean corpuscular volume, gamma-glutamyl-transferase or alanine or aspartate aminotransferase levels). In the study by Chang et al. [17] including 24 women (58% of whom had dependence, 8% of whom had abuse, and 21% of whom had a past alcohol use disorder), no difference in alcohol consumption was observed between groups, the BI was done by an experienced addiction psychiatrist, and duration was not specified. Both study samples were recruited from single clinic sites. Neither study addressed treatment linkage as a goal of BI, although in Chang et al., referral to treatment was the control condition. Despite this, no control patients followed through on the referral in that study, and linkage to treatment was not reported for the BI group.

Table 2

Alcohol screening and brief intervention trials included in the systematic review that excluded patients with very heavy alcohol use or dependence

Table 3

Alcohol screening and brief intervention trials included in the systematic review that did not exclude subjects with very heavy alcohol use or dependence

Conclusions

Results of the two studies identified in this systematic review offer no evidence to support alcohol screening and BI efficacy among primary-care patients with very heavy drinking or dependence. Further, the studies were of limited generalisability. Patient samples were small in both studies; one study included only women, and the other included only Mexican Americans; results were not specifically analysed by dependence; the range of outcome measures could have been greater; and, in one of the studies, the intervention was conducted by an expert.

Other evidence in the literature suggests that screening and BI has efficacy for those who drink too much but do not have dependence. It may turn out to have efficacy for those with more severe unhealthy use, but evidence to date is not available to support this. There is a difference between an absence of evidence and evidence for absence of effect: the circumstance here is the former. Regardless, it is clear that we cannot conclude, on the basis of high-quality evidence in the scientific literature, that BI among those identified by alcohol screening in primary care works for people with very heavy drinking or dependence.

This study had several limitations. Ideally, systematic reviews are conducted by at least two independent raters, and inter-rater reliability is reported. Such a process might have strengthened this paper. Second, the findings relied largely on prior systematic reviews, exclusion criteria in original articles were sometimes not clearly specified, and non-English language studies were not included. However, of the four non-English studies included in the prior systematic reviews, two excluded patients with dependence and patients who had received treatment for alcohol problems [32,33], one excluded patients who had received treatment [34], and one excluded people with heavy drinking (≥95 units per week) and failed to provide clear data on randomisation methods [35]. As such, these studies would have either been excluded from the current review based on criteria other than language or, if included, would have appeared among the studies that excluded patients with very heavy use or dependence (and thus would not have contributed information on efficacy of BI in such patients).

One might wonder whether the BI literature beyond primary care might inform the question asked in this review. However, the context of care appears to be quite important for BI. In the literature on BI in emergency departments, most studies found no impact of BI on drinking [36–38]. Severity may be an explanation for inconsistent results on BI efficacy in other settings, such as hospitals [39]. For example, one of the few BI studies in any setting that did not exclude people with dependence found no efficacy for BI in hospitalized patients; 77% of patients in the sample had dependence, because that was the nature of the population found in the hospital [7,40]. A subgroup analysis from the same study found there may have been an impact of BI on drinking among those without dependence only [41]. Another hospital study that excluded patients with dependence or alcohol-related conditions found the effectiveness of BI for decreasing consumption was comparable to that achieved by providing a self-help booklet compared with controls who received no intervention [42]. An additional analysis of BI in the hospital setting by Freyer-Adam et al. [43] found no difference in consumption or alcohol-related consequences among the 45% of patients with dependence. Studies that compare BI to more extensive interventions could theoretically be informative, but they have generally not included people identified by screening [6]. In such studies, BI has similar efficacy to longer interventions among those seeking help. It is not known how such results would translate to BI among people with dependence who are not necessarily seeking help.

One might consider the use of categorization of patients as having dependence a simplification of what is likely a spectrum of severity. Although it is probably true that severity of unhealthy use is on a spectrum rather than a dichotomous phenomenon, it also remains likely that, when patients are categorized as “dependent,” such categorisation includes patients with greater severity. Continuous measures of severity could be used in future studies to better identify those patients for whom BI does or does not have efficacy, but, generally speaking, studies to date have not done so.

This review has methodological strengths as well. Many systematic reviews of BI in primary care have preceded this one, making it likely that few, if any, studies have been missed. Experts in systematic-review methodology have recently encouraged the appropriate inclusion of prior systematic reviews in those that follow[44]. This review focused on the primary-care setting as defined by the US Institute of Medicine and used a wide range of electronic databases. It also excluded studies with substantial methodological limitations.

Based on this review, it is clear that most randomised trials of alcohol BI for screen-identified patients in primary-care settings published to date have excluded patients with very heavy alcohol use or dependence. In the two studies that did include patients with dependence, the efficacy of BI for such patients remains unknown.

Implications

In clinical practice, most do not advocate BI for patients with alcohol dependence, recognizing it will likely be insufficient to address this more complex and severe condition. Yet such patients often receive no intervention, whether BI or more extensive treatment. Although BI is expected to lead to referral, treatment initiation, and reductions in alcohol consumption and related problems, these results and those of other studies in other settings suggest this is unlikely. In a study of hospitalized patients by Elvy et al. [45], BI decreased alcohol-related consequences and increased treatment enrolment (14% of patients in the BI group enrolled in treatment versus 4% of patients who got no BI); however, most participants did not have dependence. In a study by Saitz et al. involving general hospital patients, no differences in treatment entry were seen, although hypothesis-generating subgroup analyses showed some promise for women and younger men with dependence [40].

Bischof et al. [46] compared computerized feedback and telephone-based care with no intervention among primary-care patients with unhealthy alcohol use, including dependence. They found a decrease in heavy drinking only among those with risky use or abuse, but no other outcome differences were observed, and no benefits were observed among patients with dependence. (Specifically, BI did not increase help-seeking.) D’onofrio et al. [47] conducted a study among emergency-department patients without dependence and found no difference in substance-abuse or mental-health treatment utilization among those receiving BI versus those receiving no intervention. Finally, although success of drug and alcohol treatment varies depending on rapid availability of treatment, the nature of treatment (e.g. opioid agonist treatment for opioid dependence versus naltrexone for alcohol dependence), and the availability of support services (e.g. transportation), US programs that provide alcohol screening, BI, and referral to treatment (SBIRT) [48] report that most patients with dependence referred to treatment do not accept the referral and, thus, do not enter treatment (Daniel Alford and Jennifer Smith, Personal Communication, December 14, 2009).

In sum, screening, even when the goal is BI for people with non-dependent unhealthy use, identifies patients with dependence, and the rationale for implementing BI universally among such patients is questionable considering the lack of evidence for its efficacy. We should not “throw the baby out with the bathwater,” however. Clearly, BI has efficacy for primary-care patients with less severe unhealthy alcohol use, and that should continue. The question is whether such screening should be universal if evidence for benefit in an important subgroup is lacking. Some might conclude that it should, because BI will eventually be proven to have efficacy among those with dependence. Others will disagree. Nonetheless, research is needed to determine what, if anything, may have efficacy for patients with alcohol dependence identified by screening in primary care as well as in other health-care settings. Such studies of BI should assess subjects with continuous measures of unhealthy alcohol use severity; be widely generalisable, with few exclusion criteria; and measure important clinical outcomes (e.g. consumption, consequences, cost, referral completion, and other health-care utilization).

The absence of evidence for the efficacy of BI among primary-care patients with screening-identified alcohol dependence raises questions regarding the efficiency of screening and BI, particularly in settings where dependence is common. The finding also highlights the need for developing new approaches to help such patients, particularly if screening and BI are to be disseminated widely.

Supplementary Material

Supp Apps 1

Click here to view.^{(46K, doc)}

Supp Apps 2

Click here to view.^{(55K, doc)}

Acknowledgments

Dr. Saitz would like to thank Donna Vaillancourt for editorial preparation of the manuscript for publication. His research is supported in part by support from the US National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse (grant numbers R01DA025068 and R01AA10019).

References

1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ. 2003;327:536–42. [PMC free article] [PubMed]

2. Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med. 2005;165:986–95. [PubMed]

3. Kaner EF, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: A systematic review. Drug Alcohol Rev. 2009;28:301–23. [PubMed]

4. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:557–68. [PubMed]

5. Manwell LB, Fleming MF, Johnson K, Barry KL. Tobacco, alcohol, and drug use in a primary care sample: 90-day prevalence and associated factors. J Addict Dis. 1998;17:67–81. [PubMed]

6. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction. 2002;97:279–92. [PubMed]

7. Saitz R, Freedner N, Palfai TP, Horton NJ, Samet JH. The severity of unhealthy alcohol use in hospitalized medical patients. The spectrum is narrow. J Gen Intern Med. 2006;21:381–5. [PMC free article] [PubMed]

8. Bischof G, Freyer-Adam J. Brief intervention for medical inpatients with unhealthy alcohol use. Comment Ann Intern Med. 2007;147:589. [PubMed]

9. US Institute of Medicine Committee on the Future of Primary Care. Primary Care: America’s Health in a New Era. Executive Summary. 1996. [Accessed May 20, 2010]. p. 1. Available at http://www.nap.edu/nap-cgi/report.cgi?record_id=5152&type=pdfxsum.

10. Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001;20:21–35. [PubMed]

11. Cochrane Drugs and Alcohol Group. Resources for review authors: guidelines to assess study quality. 2003. [Accessed May 20, 2010]. Available from: http://cdag.cochrane.org/resources-review-authors.

12. Kahan M, Wilson L, Becker L. Effectiveness of physician-based interventions with problem drinkers: a review. CMAJ. 1995;152:851–9. [PMC free article] [PubMed]

13. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med. 1997;12:274–83. [PMC free article] [PubMed]

14. Poikolainen K. Effectiveness of brief interventions to reduce alcohol intake in primary health care populations: a meta-analysis. Prev Med. 1999;28:503–9. [PubMed]

15. Ballesteros J, Duffy JC, Querejeta I, Arino J, Gonzalez-Pinto A. Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses. Alcohol Clin Exp Res. 2004;28:608–18. [PubMed]

16. Anderson P, Scott E. The effect of general practitioners’ advice to heavy drinking men. Br J Addict. 1992;87:891–900. [PubMed]

17. Chang G, Behr H, Goetz MA, Hiley A, Bigby J. Women and alcohol abuse in primary care. Identification and intervention. Am J Addict. 1997;6:183–92. [PubMed]

18. Curry SJ, Ludman EJ, Grothaus LC, Donovan D, Kim E. A randomized trial of a brief primary-care-based intervention for reducing at-risk drinking practices. Health Psychol. 2003;22:156–65. [PubMed]

19. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA. 1997;277:1039–45. [PubMed]

20. Fleming MF, Manwell LB, Barry KL, Adams W, Stauffacher EA. Brief physician advice for alcohol problems in older adults: a randomized community-based trial. J Fam Pract. 1999;48:378–84. [PubMed]

21. Lock CA, Kaner E, Heather N, et al. Effectiveness of nurse-led brief alcohol intervention: a cluster randomized controlled trial. J Adv Nurs. 2006;54:426–39. [PubMed]

22. Maisto SA, Conigliaro J, McNeil M, Kraemer K, Conigliaro RL, Kelley ME. Effects of two types of brief intervention and readiness to change on alcohol use in hazardous drinkers. J Stud Alcohol. 2001;62:605–14. [PubMed]

23. Nilssen O. The Tromso Study: identification of and a controlled intervention on a population of early-stage risk drinkers. Prev Med. 1991;20:518–28. [PubMed]

24. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? Arch Intern Med. 1999;159:2198–205. [PubMed]

25. Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction. 1995;90:119–32. [PubMed]

26. Scott E, Anderson P. Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption. Drug Alcohol Rev. 1991;10:313–21. [PubMed]

27. Senft RA, Polen MR, Freeborn DK, Hollis JF. Brief intervention in a primary care setting for hazardous drinkers. Am J Prev Med. 1997;13:464–70. [PubMed]

28. Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ. 1988;297:663–8. [PMC free article] [PubMed]

29. WHO Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. Am J Public Health. 1996;86:948–55. [PubMed]

30. Burge SK, Amodei N, Elkin B, et al. An evaluation of two primary care interventions for alcohol abuse among Mexican-American patients. Addiction. 1997;92:1705–16. [PubMed]

31. Schaus JF, Sole ML, McCoy TP, Mullett N, O’Brien MC. Alcohol screening and brief intervention in a college student health center: a randomized controlled trial. J Stud Alcohol Drugs Suppl. 2009;16:131–41. [PubMed]

32. Altisent R, Cordoba R, Delgado MT, et al. Multicenter study on the efficacy of advice for the prevention of alcoholism in primary health care. Med Clin (Barc) 1997;109:121–4. [PubMed]

33. Huas D, Pessione F, Bouix JC, Demeaux JL, Allemand H, Rueff B. Efficacité à un an d’une intervention brève auprès des consommateurs d’alcool à problèmes. Rev Praticien Méd Gén. 2002;16:1343–8.

34. Fernandez San Martin MI, Bermejo Caja CJ, Alonso Perez M, et al. Effectiveness of brief medical counseling to reduce drinkers’ alcohol consumption. Aten Primaria. 1997;19:127–32. [PubMed]

35. Diez JF, Pena C, Garcia E, Gaite L. Brief intervention in Cantabria (Spain) in alcohol related problems. [Intervencion breve en Cantabria en problemas relacionados con el alcohol] Adicciones. 2002;14:13–24.

36. Havard A, Shakeshaft A, Sanson-Fisher R. Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries. Addiction. 2008;103:368–76. [PubMed]

37. Nilsen P, Baird J, Mello MJ, et al. A systematic review of emergency care brief alcohol interventions for injury patients. J Subst Abuse Treat. 2008;35:184–201. [PubMed]

38. Bernstein E, Bernstein JA, Stein JB, Saitz R. SBIRT in emergency care settings: are we ready to take it to scale? Acad Emerg Med. 2009;16:1072–7. [PubMed]

39. McQueen J, Howe TE, Allan L, et al. Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database Syst Rev. 2009;3:CD005191. [PubMed]

40. Saitz R, Palfai TP, Cheng DM, et al. Brief intervention for medical inpatients with unhealthy alcohol use: a randomized, controlled trial. Ann Intern Med. 2007;146:167–76. [PubMed]

41. Saitz R, Palfai TP, Cheng DM, et al. Some medical inpatients with unhealthy alcohol use may benefit from brief intervention. J Stud Alcohol Drugs. 2009;70:426–35. [PubMed]

42. Holloway AS, Watson HE, Arthur AJ, Starr G, McFadyen AK, McIntosh J. The effect of brief interventions on alcohol consumption among heavy drinkers in a general hospital setting. Addiction. 2007;102:1762–70. [PubMed]

43. Freyer-Adam J, Coder B, Baumeister SE, et al. Brief alcohol intervention for general hospital inpatients: a randomized controlled trial. Drug Alcohol Depend. 2008;93:233–43. [PubMed]

44. Whitlock EP, Lin JS, Chou R, Shekelle P, Robinson KA. Using existing systematic reviews in complex systematic reviews. Ann Intern Med. 2008;148:776–82. [PubMed]

45. Elvy GA, Wells JE, Baird KA. Attempted referral as intervention for problem drinking in the general hospital. Br J Addict. 1988;83:83–9. [PubMed]

46. Bischof G, Grothues JM, Reinhardt S, Meyer C, John U, Rumpf HJ. Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: a randomized controlled trial. Drug Alcohol Depend. 2008;93:244–51. [PubMed]

47. D’Onofrio G, Pantalon MV, Degutis LC, et al. Brief intervention for hazardous and harmful drinkers in the emergency department. Ann Emerg Med. 2008;51:742, 750.e2. [PMC free article] [PubMed]

48. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:280–95. [PMC free article] [PubMed]

49. Aalto M, Saksanen R, Laine P, et al. Brief intervention for female heavy drinkers in routine general practice: a 3-year randomized, controlled study. Alcohol Clin Exp Res. 2000;24:1680–6. [PubMed]

50. Aalto M, Seppa K, Mattila P, et al. Brief intervention for male heavy drinkers in routine general practice: a three-year randomized controlled study. Alcohol Alcohol. 2001;36:224–30. [PubMed]

51. Cordoba R, Delgado MT, Pico V, et al. Effectiveness of brief intervention on non-dependent alcohol drinkers (EBIAL): a Spanish multi-centre study. Fam Pract. 1998;15:562–8. [PubMed]

52. Crawford MJ, Patton R, Touquet R, et al. Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet. 2004;364:1334–9. [PubMed]

53. Fleming M, Brown R, Brown D. The efficacy of a brief alcohol intervention combined with %CDT feedback in patients being treated for type 2 diabetes and/or hypertension. J Stud Alcohol. 2004;65:631–7. [PubMed]

54. Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230:473–80. [PubMed]

55. Guth S, Lindberg SA, Badger GJ, Thomas CS, Rose GL, Helzer JE. Brief intervention in alcohol- dependent versus nondependent individuals. J Stud Alcohol Drugs. 2008;69:243–50. [PubMed]

56. Heather N, Campion PD, Neville RG, Maccabe D. Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS scheme) J R Coll Gen Pract. 1987;37:358–63. [PMC free article] [PubMed]

57. Israel Y, Hollander O, Sanchez-Craig M, et al. Screening for problem drinking and counseling by the primary care physician-nurse team. Alcohol Clin Exp Res. 1996;20:1443–50. [PubMed]

58. Kuchipudi V, Hobein K, Flickinger A, Iber FL. Failure of a 2-hour motivational intervention to alter recurrent drinking behavior in alcoholics with gastrointestinal disease. J Stud Alcohol. 1990;51:356–60. [PubMed]

59. Kunz FM, Jr, French MT, Bazargan-Hejazi S. Cost-effectiveness analysis of a brief intervention delivered to problem drinkers presenting at an inner-city hospital emergency department. J Stud Alcohol. 2004;65:363–70. [PubMed]

60. 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. Arch Intern Med. 2008;168:530–6. [PubMed]

61. Lee HS, Mericle AA, Ayalon L, Arean PA. Harm reduction among at-risk elderly drinkers: a site-specific analysis from the multi-site Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study. Int J Geriatr Psychiatry. 2009;24:54–60. [PubMed]

62. Longabaugh R, Woolard RE, Nirenberg TD, et al. Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department. J Stud Alcohol. 2001;62:806–16. [PubMed]

63. Maheswaran R, Beevers M, Beevers DG. Effectiveness of advice to reduce alcohol consumption in hypertensive patients. Hypertension. 1992;19:79–84. [PubMed]

64. Manwell LB, Fleming MF, Mundt MP, Stauffacher EA, Barry KL. Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial. Alcohol Clin Exp Res. 2000;24:1517–24. [PubMed]

65. McIntosh MC, Leigh G, Baldwin NJ, Marmulak J. Reducing alcohol consumption. Comparing three brief methods in family practice. Can Fam Physician. 1997;43:1959, 62, 1965–7. [PMC free article] [PubMed]

66. 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. Psychiatr Serv. 2006;57:954–8. [PMC free article] [PubMed]

67. Pal HR, Yadav D, Mehta S, Mohan I. A comparison of brief intervention versus simple advice for alcohol use disorders in a North India community-based sample followed for 3 months. Alcohol Alcohol. 2007;42:328–32. [PubMed]

68. Persson J, Magnusson PH. Early intervention in patients with excessive consumption of alcohol: a controlled study. Alcohol. 1989;6:403–8. [PubMed]

69. Reinhardt S, Bischof G, Grothues J, John U, Meyer C, Rumpf HJ. Gender differences in the efficacy of brief interventions with a stepped care approach in general practice patients with alcohol-related disorders. Alcohol Alcohol. 2008;43:334–40. [PubMed]

70. Rodriguez-Martos A, Santamarina E, Torralba L, Escayola M, Marti J, Plasencia A. Short-term effectiveness of brief interventions in alcohol-positive traffic casualties. Gac Sanit. 2005;19:45–9. [PubMed]

71. Romelsjo A, Andersson L, Barrner H, et al. A randomized study of secondary prevention of early stage problem drinkers in primary health care. Br J Addict. 1989;84:1319–27. [PubMed]

72. Rose HL, Miller PM, Nemeth LS, et al. Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention. Addiction. 2008;103:1271–80. [PubMed]

73. Salaspuro M. Intervention against hazardous alcohol consumption: secondary prevention of alcohol problems. In: Berglund M, Thelander S, Jonsson E, editors. Treating alcohol and drug abuse: an evidence based review. Weinheim, Germany: Wiley-VCH; 2003. pp. 1–41.

74. Seppä K. Intervention in alcohol abuse among macrocytic patients in general practice. Scand J Prim Health Care. 1992;10:217–22. [PubMed]

75. Tomson Y, Romelsjo A, Aberg H. Excessive drinking--brief intervention by a primary health care nurse. A randomized controlled trial. Scand J Prim Health Care. 1998;16:188–92. [PubMed]