Related Articles

Background

There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption. In older populations excessive alcohol consumption is associated with increased risk of coronary heart disease, hypertension, stroke and a range of cancers. Alcohol consumption is also associated with an increased risk of falls, early onset of dementia and other cognitive deficits. Physiological changes that occur as part of the ageing process mean that older people experience alcohol related problems at lower consumption levels. There is a strong evidence base for the effectiveness of brief psychosocial interventions in reducing alcohol consumption in populations identified opportunistically in primary care settings. Stepped care interventions involve the delivery of more intensive interventions only to those in the population who fail to respond to less intensive interventions and provide a potentially resource efficient means of meeting the needs of this population.

Methods/design

The study design is a pragmatic prospective multi-centre two arm randomised controlled trial. The primary hypothesis is that stepped care interventions for older hazardous alcohol users reduce alcohol consumption compared with a minimal intervention at 12 months post randomisation. Potential participants are identified using the AUDIT questionnaire. Eligible and consenting participants are randomised with equal probability to either a minimal intervention or a three step treatment approach. The step treatment approach incorporates as step 1 behavioural change counselling, step 2 three sessions of motivational enhancement therapy and step 3 referral to specialist services. The primary outcome is measured using average standard drinks per day and secondary outcome measures include the Drinking Problems Index, health related quality of life and health utility. The study incorporates a comprehensive economic analysis to assess the relative cost-effectiveness of the interventions.

Discussion

The paper presents a protocol for the first pragmatic randomised controlled trial evaluating the effectiveness and cost-effectiveness of stepped care interventions for older hazardous alcohol users in primary care.

Trial registration

ISRCTN52557360

BACKGROUND: The effectiveness of an evidence-based health care intervention depends on it being delivered consistently to appropriate patients. Brief alcohol intervention is known to be effective at reducing excessive drinking and its concomitant health and social problems. However, a recent implementation trial reported partial delivery of brief alcohol intervention by general practitioners (GPs) which is likely to have reduced its impact. AIM: To investigate patient-practitioner characteristics influencing brief alcohol intervention in primary care. DESIGN OF STUDY: Cross-sectional analysis of 12,814 completed Alcohol Use Disorders Identification Test (AUDIT) screening questionnaires. SETTING: Eighty-four GPs who had implemented a brief alcohol intervention programme in a previous trial based in the Northeast of England. METHOD: GPs were requested to screen all adults (aged over 16 years) presenting to their surgery and follow a structured protocol to give a brief intervention (five minutes of advice plus an information booklet) to all 'risk' drinkers. Anonymized carbon copies of the screening questionnaire were collected from all practices after a three-month implementation period. RESULTS: Although AUDIT identified 4080 'risk' drinkers, only 2043 (50%) received brief intervention. Risk drinkers that were most likely to receive brief intervention were males (58%), unemployed (61%), and technically-trained patients (55%). Risk drinkers that were least likely to receive brief intervention were females (44%), students (38%), and university educated patients (46%). Logistic regression modelling showed that patients' risk status was the most influential predictor of brief intervention. Also, GPs' experience of relevant training and longer average practice consultations predicted brief intervention. However, personal characteristics relating to patients and GPs also predicted brief intervention in routine practice. CONCLUSION: Interpersonal factors relating to patients and practitioners contributed to the selective provision of brief alcohol intervention in primary care. Ways should be found to remedy this situation or the impact of this evidence-based intervention may be reduced when implemented in routine practice.

HIV-infected patients have considerable need for alcohol reduction support, and HIV care providers are strategically placed to implement a “prevention for positives” alcohol reduction approach through alcohol screening and brief interventions (SBIs). To facilitate this approach, we provided alcohol SBI education and training to HIV care providers in four hospital-based, New York City HIV Care Centers in 2007. Interviews with the medical directors and 14 of the HIV care providers who attended the training identified barriers to implementing alcohol SBIs. These included limited time for alcohol screening, patients’ incomplete disclosure of alcohol use, providers’ perceptions that alcohol use is not a major problem for their patients, and provider specialization that assigns patients with problematic alcohol use to specifically designated providers. Identified facilitators for alcohol SBI implementation included adequate time to conduct the SBI; availability of information, tools, and key points to emphasize with HIV-infected patients; and use of a brief alcohol screening tool.

Background

Alcohol screening and brief intervention for unhealthy alcohol use has not been consistently delivered in primary care as part of preventive healthcare.

Objective

To explore whether telephone-based intervention delivered by a health educator is efficacious in reducing at-risk drinking among older adults in primary care settings.

Design

Secondary analyses of data from a randomized controlled trial.

Participants

Subjects randomized to the intervention arm of the trial (n = 310).

Interventions

Personalized risk reports, advice from physicians, booklet about alcohol and aging, and up to three telephone calls from a health educator. All interventions were completed before the three-month follow-up.

Measurements

Risk outcomes (at-risk or not at-risk) at 3 and 12 months after enrollment.

Main results

In univariate analyses, compared to those who remained at risk, those who achieved not at-risk outcome at 3 months were more likely to be women, Hispanic or non-white, have lower levels of education, consume less alcohol, drink less frequently, and have lower baseline number of risks. In mixed-effects logistic regression models, completing all three health educator calls increased the odds of achieving not at-risk outcome compared to not completing any calls at 3 months (OR 5.31; 95% CI 1.92–14.7; p = 0.001), but not at 12 months (OR 2.01; 95% CI 0.71–5.67; p = 0.18).

Conclusions

Telephone-based intervention delivered by a health educator was moderately efficacious in reducing at-risk drinking at 3 months after enrollment among older adults receiving a multi-faceted intervention in primary care settings; however, the effect was not sustained at 12 months.

Objective To determine the effectiveness of programmes of screening in general practice for excessive alcohol use and providing brief interventions.

Design Systematic review and meta-analysis of randomised controlled trials that used screening as a precursor to brief intervention.

Setting General practice.

Main outcome measures Number needed to treat, proportion of patients positive on screening, proportion given brief interventions, and effect of screening.

Results The eight studies included for meta-analysis all used health questionnaires for screening, and the brief interventions included feedback, information, and advice. The studies contained several sources of bias that might lead to overestimates of the effects of intervention. External validity was compromised because typically three out of four people identified by screening as excessive users of alcohol did not qualify for the intervention after a secondary assessment. Overall, in 1000 screened patients, 90 screened positive and required further assessment, after which 25 qualified for brief intervention; after one year 2.6 (95% confidence interval 1.7 to 3.4) reported they drank less than the maximum recommended level.

Conclusions Although even brief advice can reduce excessive drinking, screening in general practice does not seem to be an effective precursor to brief interventions targeting excessive alcohol use. This meta-analysis raises questions about the feasibility of screening in general practice for excessive use of alcohol.

Background

The Patient Protection and Affordable Care Act of 2010 supports integration of substance abuse interventions and treatments into the mainstream health care system. Thus, effective screening and intervention for substance use disorders in health care settings is a priority.

Objective

This paper reviews the prevalence of alcohol and drug use disorders (abuse or dependence) in primary care settings and emergency departments, as well as current screening tools and brief interventions.

Methods

MEDLINE was searched using the following keywords: alcohol use, alcohol use disorder, drug use, drug use disorder, screening, primary care, and emergency departments. Using the related-articles link, additional articles were screened for inclusion. This review focuses on alcohol and drug use and related disorders among adults in primary care settings.

Conclusion

Screening, brief intervention, and referral for treatment are feasible and effective in primary care settings, provided that funding for screening is available, along with brief interventions and treatment facilities to which patients can be referred and treated promptly.

Twenty-eight patients with diabetes who screened positive for at-risk drinking were assigned to brief alcohol intervention (BAI) (n = 14) or standard care (SC) (n = 14) treatment conditions. All participants completed a baseline interview and one-, three, and six-month follow-up interviews. Across the six-month follow-up period, there was a significantly greater reduction in quantity of alcohol consumed in the BAI group. At the six-month follow-up, the BAI group had a greater reduction in quantity of alcohol consumed, percentage of heavy drinking days, and frequency of drinking. Reductions in alcohol use were associated with improved adherence in certain components of diabetes self-care behavior. The results of this study suggest that brief alcohol interventions are efficacious in reducing alcohol use among at-risk drinkers with diabetes and that reductions in alcohol use may result in some improvements in adherence to diabetes self-care behavior.

Twenty-eight patients with diabetes who screened positive for at-risk drinking were assigned to brief alcohol intervention (BAI) (n = 14) or standard care (SC) (n = 14) treatment conditions. All participants completed a baseline interview and one-, three, and six-month follow-up interviews. Across the six-month follow-up period, there was a significantly greater reduction in quantity of alcohol consumed in the BAI group. At the six-month follow-up, the BAI group had a greater reduction in quantity of alcohol consumed, percentage of heavy drinking days, and frequency of drinking. Reductions in alcohol use were associated with improved adherence in certain components of diabetes self-care behavior. The results of this study suggest that brief alcohol interventions are efficacious in reducing alcohol use among at-risk drinkers with diabetes and that reductions in alcohol use may result in some improvements in adherence to diabetes self-care behavior.

Objectives

The study objective was to assess the feasibility of a computerized alcohol-screening interview (CASI) program to identify at-risk alcohol users among adult emergency department (ED) patients. The study aimed to evaluate the feasibility of implementing a computerized screening, brief intervention, and referral to treatment (SBIRT) program within a busy urban ED setting, to report on accurate deployment of alcohol screening results, and to assess comprehension and satisfaction with CASI from both patient and research staff perspectives.

Methods

Research assistants (RAs) screened a convenience sample of medically stable ED patients. The RAs brought CASI to patients’ bedsides, and patients entered their own alcohol consumption data. The CASI intervention consisted of an alcohol use screening identification test, a personalized normative feedback profile, NIAAA low-risk drinking educational materials, and treatment referrals (when indicated).

Results

Five hundred seventeen patients were enrolled. The median age of participants was 37 years (range, 21-85 years); 37% were men, 62% were Hispanic, 7% were Caucasian, 30% were African American, and 2% were multiracial. Eighty percent reported regular use of computers at home. Eighty percent of patients approached consented to participate, and 99% of those who started CASI were able to complete it. Two percent of interviews were interrupted for medical tests and procedures, however, no patients required breaks from using CASI for not feeling well. The CASI program accurately provided alcohol risk education to patients 100% of the time. Thirty-two percent of patients in the sample screened positive for at-risk drinking. Sixty percent of patients reported that CASI increased their knowledge of safe drinking limits, 39% reported some likeliness to change their alcohol use, and 28% reported some intention to consult a health care professional about their alcohol use as a result of their screening results. Ninety-three percent reported CASI was easy to use, 93% felt comfortable receiving alcohol education via computer, and 89% liked using CASI. Ninety percent of patients correctly identified their alcohol risk level after participating in CASI. With regard to research staff experience, RAs needed to provide standby assistance to patients during <1% of CASI administrations and needed to troubleshoot computer issues in 4% of interviews. The RAs distributed the correct alcohol risk normative profiles to patients 97% of the time and provided patients with treatment referrals when indicated 81% of the time. The RAs rated patients as “not bothered at all” by using CASI 94% of the time.

Conclusions

This study demonstrates that an ED-based computerized alcohol screening program is both acceptable to patients and effective in educating patients about their alcohol risk level. Additionally, this study demonstrates that few logistical problems related to using computers for these interventions were experienced by research staff: in most cases, staff accurately deployed alcohol risk education to patients, and in all cases, the computer provided accurate education to patients. Computer-assisted SBIRT may represent a significant time-saving measure, allowing EDs to reach larger numbers of patients for alcohol intervention without causing undue clinical burden or interruptions to clinical care. Future studies with follow-up are needed to replicate these results and assess drinking reductions post-intervention.

Introduction

Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the World Health Organization (WHO) as one of the top five risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption. This review covers interventions in hazardous or harmful, but not dependent, alcohol users.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions in hazardous or harmful drinkers in the primary-care setting? What are the effects of interventions in hazardous or harmful drinkers in the emergency-department setting? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 18 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review, we present information relating to the effectiveness and safety of the following interventions in primary care and in emergency departments: brief intervention (single- or multiple-session); universal screening plus brief interventions; and targeted screening plus brief interventions.

Key Points

Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the WHO as one of the top five risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption.

This review covers interventions in hazardous or harmful (but not dependent) alcohol users. Hazardous alcohol consumption is defined as a pattern of alcohol consumption that increases the individual's risk of alcohol-related harm, but is not currently causing alcohol-related harm.Harmful alcohol consumption is a pattern of consumption likely to have already led to alcohol-related harm.

Single- or multiple-session brief intervention reduces alcohol consumption over 1 year in hazardous drinkers treated in the primary-care setting, but we don't know how it affects mortality.

Brief intervention (single- or multiple-session) is also effective at reducing alcohol consumption in people treated in the emergency department, although the evidence is not as strong.

Adding universal screening to brief intervention enhances its benefits when given in primary care. We don't know how effectiveuniversal screening in emergency departments is, as we found no data.We don't know whether targeted screening is effective, as we found no data assessing its use in primary or emergency care.

Background

There have been many randomized controlled trials of screening and brief alcohol intervention in primary care. Most trials have reported positive effects of brief intervention, in terms of reduced alcohol consumption in excessive drinkers. Despite this considerable evidence-base, key questions remain unanswered including: the applicability of the evidence to routine practice; the most efficient strategy for screening patients; and the required intensity of brief intervention in primary care. This pragmatic factorial trial, with cluster randomization of practices, will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in primary care and different intensities of brief intervention to reduce excessive drinking in primary care patients.

Methods and design

GPs and nurses from 24 practices across the North East (n = 12), London and South East (n = 12) of England will be recruited. Practices will be randomly allocated to one of three intervention conditions: a leaflet-only control group (n = 8); brief structured advice (n = 8); and brief lifestyle counselling (n = 8). To test the relative effectiveness of different screening methods all practices will also be randomised to either a universal or targeted screening approach and to use either a modified single item (M-SASQ) or FAST screening tool. Screening randomisation will incorporate stratification by geographical area and intervention condition. During the intervention stage of the trial, practices in each of the three arms will recruit at least 31 hazardous or harmful drinkers who will receive a short baseline assessment followed by brief intervention. Thus there will be a minimum of 744 patients recruited into the trial.

Discussion

The trial will evaluate the impact of screening and brief alcohol intervention in routine practice; thus its findings will be highly relevant to clinicians working in primary care in the UK. There will be an intention to treat analysis of study outcomes at 6 and 12 months after intervention. Analyses will include patient measures (screening result, weekly alcohol consumption, alcohol-related problems, public service use and quality of life) and implementation measures from practice staff (the acceptability and feasibility of different models of brief intervention.) We will also examine organisational factors associated with successful implementation.

Trial registration

Current Controlled Trials ISRCTN06145674.

Background

Despite the enormous burden of alcohol-related injuries, the direct connection between college drinking and physical injury has not been well understood. The goal of this study is to assess the connection between alcohol consumption levels and college alcohol-related injury risk.

Methods

12,900 college students seeking routine care in 5 college health clinics completed a general Health Screening Survey. 2,090 of these students exceeded at-risk alcohol use levels and participated in a face-to-face interview to determine eligibility for a brief alcohol intervention trial. The eligibility interview assessed past 28-day alcohol use and alcohol-related injuries in the past 6 months. Risk of alcohol-related injury was compared across daily drinking quantities and frequencies. Logistic regression analysis and the Bayesian Information Criterion were applied to compute the odds of alcohol-related injury based on daily drinking totals after adjusting for age, race, site, body weight and sensation seeking.

Results

Male college students in the study were 19% more likely (95% CI: 1.12–1.26) to suffer an alcohol-related injury with each additional day of consuming 8 or more drinks. Injury risks among males increased marginally with each day of consuming 5–7 drinks (Odds ratio=1.03, 95% CI: 0.94–1.13). Female participants were 10% more likely (95% CI: 1.04–1.16) to suffer an alcohol-related injury with each additional day of drinking 5 or more drinks. Males (OR=1.69, 95% CI: 1.14–2.50) and females (OR=1.81, 95% CI: 1.27–2.57) with higher sensation seeking scores were more likely to suffer alcohol-related injuries.

Conclusions

College health clinics may want to focus limited alcohol injury prevention resources on students who frequently engage in extreme drinking, defined in this study as 8+M/5+F drinks per day, and score high on sensation seeking disposition.

Background

Alcohol dependence affects approximately 3% of the English population, and accounts for significant medical and psychiatric morbidity. Only 5.6% of alcohol-dependent individuals ever access specialist treatment and only a small percentage ever seek treatment. As people who are alcohol dependent are more likely to have experienced health problems leading to frequent attendance at acute hospitals it would seem both sensible and practical to ensure that this setting is utilised as a major access point for treatment, and to test the effectiveness of these treatments.

Methods/Design

This is a randomised controlled trial with a primary hypothesis that extended brief interventions (EBI) delivered to alcohol-dependent patients in a hospital setting by an Alcohol Specialist Nurse (ASN) will be effective when compared to usual care in reducing overall alcohol consumption and improving on the standard measures of alcohol dependence. Consecutive patients will be screened for alcohol misuse in the Emergency Department (ED) of a district general hospital. On identification of an alcohol-related problem, following informed written consent, we aim to randomize 130 patients per group. The ASN will discharge to usual clinical care all control group patients, and plan a programme of EBI for treatment group patients. Follow-up interview will be undertaken by a researcher blinded to the intervention at 12 and 24 weeks. The primary outcome measure is level of alcohol dependence as determined by the Severity of Alcohol Dependence Questionnaire (SADQ) score. Secondary outcome measures include; Alcohol Use Disorders Identification Test (AUDIT) score, quantity and frequency of alcohol consumption, health-related quality of life measures, service utilisation, and patient experience. The trial will also allow an assessment of the cost-effectiveness of EBI in an acute hospital setting. In addition, patient experience will be assessed using qualitative methods.

Discussion

This paper presents a protocol for a RCT of EBI delivered to alcohol dependent patients by an ASN within an ED. Importantly; the trial will also seek to understand patients' perceptions and experiences of being part of a RCT and of receiving this form of intervention.

Trial registration number

ISRCTN: ISRCTN78062794

This clinical trial compared two brief alcohol use interventions in prenatal clinics: Early Start (ES), a substance abuse screening and treatment program integrated with prenatal care focused on abstention (n=298), and Early Start Plus (ESP), adding a computerized drink-size assessment tool and intervention focused on drinking less (n=266). Controls were untreated alcohol users (n=344). Controls had higher adverse neonatal and maternal outcome rates. Findings favored ESP for preterm labor and ES for low birth weight. No differences between ES and ESP were statistically significant. ESP provides clinicians with an innovative assessment tool that creates open dialogue about drinking during pregnancy.

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.

Background

Effective prevention of excessive alcohol use has the potential to reduce the public burden of disease considerably. We investigated the cost-effectiveness of Screening and Brief Intervention (SBI) for excessive alcohol use in primary care in the Netherlands, which is targeted at early detection and treatment of ‘at-risk’ drinkers.

Methodology and Results

We compared a SBI scenario (opportunistic screening and brief intervention for ‘at-risk’ drinkers) in general practices with the current practice scenario (no SBI) in the Netherlands. We used the RIVM Chronic Disease Model (CDM) to extrapolate from decreased alcohol consumption to effects on health care costs and Quality Adjusted Life Years (QALYs) gained. Probabilistic sensitivity analysis was employed to study the effect of uncertainty in the model parameters. In total, 56,000 QALYs were gained at an additional cost of €298,000,000 due to providing alcohol SBI in the target population, resulting in a cost-effectiveness ratio of €5,400 per QALY gained.

Conclusion

Prevention of excessive alcohol use by implementing SBI for excessive alcohol use in primary care settings appears to be cost-effective.

Background

The aim of the current study is to evaluate the effectiveness of serial screening methods for the identification of injured patients at risk for alcohol problems and are most likely to benefit from brief interventions. We hypothesize that blood alcohol concentration (BAC) alone is not sufficient to effectively identify at-risk drinkers in the trauma care setting.

Methods

During a 2-year period, patients admitted to an urban Level I trauma center for treatment of an injury were screened for alcohol problems. Screening consisted of four serial screening criteria: (1) clinical indication of acute intoxication including positive BAC; (2) self-reported drinking 6 hours before injury; (3) at-risk drinking as defined by National Institutes on Alcohol Abuse and Alcoholism or (4) by responding yes to one or more items on the CAGE within the last year.

Results

In all, 11,028 patients were seen. Fifty-eight percent were eligible for screening and 90% of eligible patients were screened. Of screened patients, 41% screened positive for an alcohol-related injury. Of patients that did not have a BAC drawn, 39% (n = 935) went on to screen positive using serial screening procedures. Additionally, 36% (n = 339) of patients with a negative BAC went on to screen positive using serial screening procedures.

Conclusions

This evaluation clearly suggests that BAC alone is not sufficient to identify patients who are most likely to benefit from brief alcohol interventions. Self-reported drinking in conjunction with BAC facilitates identification and intervention of injured patients with alcohol problems.

Introduction

There is a strong body of evidence demonstrating the effectiveness of brief interventions by primary care professionals for risky drinkers. However, implementation levels remain low because of time constraints and other factors. Facilitated access to an alcohol reduction website offers primary care professionals a time-saving alternative to standard face-to-face intervention, but it is not known whether it is as effective.

Methods and analysis

A randomised controlled non-inferiority trial for risky drinkers comparing facilitated access to a dedicated website with standard face-to-face brief intervention to be conducted in primary care settings in the Region of Friuli Giulia Venezia, Italy. Adult patients will be given a leaflet inviting them to log on to a website to complete the Alcohol Use Disorders Identification Test (AUDIT-C) alcohol screening questionnaire. Screen positives will be requested to complete an online trial module including consent, baseline assessment and randomisation to either standard intervention by the practitioner or facilitated access to an alcohol reduction website. Follow-up assessment of risky drinking will be undertaken online at 1 month, 3 months and 1 year using the full AUDIT questionnaire. Proportions of risky drinkers in each group will be calculated and non-inferiority assessed against a specified margin of 10%. Assuming a reduction of 30% of risky drinkers receiving standard intervention, 1000 patients will be required to give 90% power to reject the null hypothesis.

Ethics and dissemination

The protocol was approved by the Isontina Independent Local Ethics Committee on 14 June 2012. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and public events involving the local administrations of the towns where the trial participants are resident.

Registration details

Trial registration number NCT: 01638338.

Methods: Patients presenting to an accident and emergency department (AED) were screened using the Paddington Alcohol Test (PAT). All patients identified as hazardous drinkers were given written information and offered an appointment with an alcohol health worker (AHW) to discuss their drinking. Data was collected on patients' age, gender, presenting condition, and alcohol consumption. Binary logistic regression was used to identify variables that predicted attendance at the appointment with the AHW among those who accepted advice.

Results: Patients who attended the appointment were older than those who did not. Those who believed their attendance in the AED was related to alcohol were also more likely to receive brief intervention.

Conclusions: Clinicians should explore patients' perceptions of the link between their alcohol consumption and AED attendance, and where appropriate emphasise the potential association.

Background

In 2008 the World Health Organization (WHO) reported that South Africa had the highest tuberculosis (TB) incidence in the world. This high incidence rate is linked to a number of factors, including HIV co-infection and alcohol use disorders. The diagnosis and treatment package for TB and HIV co-infection is relatively well established in South Africa. However, because alcohol use disorders may present more insidiously, making it difficult to diagnose, those patients with active TB and misusing alcohol are not easily cured from TB. With this in mind, the primary purpose of this cluster randomized controlled trial is to provide screening for alcohol misuse and to test the efficacy of brief interventions in reducing alcohol intake in those patients with active TB found to be misusing alcohol in primary health care clinics in three provinces in South Africa.

Methods/Design

Within each of the three selected health districts with the highest TB burden in South Africa, 14 primary health care clinics with the highest TB caseloads will be selected. Those agreeing to participate will be stratified according to TB treatment caseload and the type of facility (clinic or community health centre). Within strata from 14 primary care facilities, 7 will be randomly selected into intervention and 7 to control study clinics (42 clinics, 21 intervention clinics and 21 control clinics). At the clinic level systematic sampling will be used to recruit newly diagnosed TB patients. Those consenting will be screened for alcohol misuse using the AUDIT. Patients who screen positive for alcohol misuse over a 6-month period will be given either a brief intervention based on the Information-Motivation-Behavioural Skills (IMB) Model or an alcohol use health education leaflet.

A total sample size of 520 is expected.

Discussion

The trial will evaluate the impact of alcohol screening and brief interventions for patients with active TB in primary care settings in South Africa. The findings will impact public health and will enable the health ministry to formulate policy related to comprehensive treatment for TB and alcohol misuse, which will result in reduction in alcohol use and ultimately improve the TB cure rates.

Trial registration number

PACTR: PACTR201105000297151

Effective implementation of evidence-based interventions in “real-world” settings can be challenging. Interventions based on externally valid trial findings can be even more difficult to apply in resource-limited settings, given marked differences—in provider experience, patient population, and health systems—between those settings and the typical clinical trial environment. Under the auspices of the Integrated Management of Physician-Delivered Alcohol Care for Tuberculosis Patients (IMPACT) study, a randomized, controlled effectiveness trial, and as an integrated component of tuberculosis treatment in Tomsk, Russia, we adapted two proven alcohol interventions to the delivery of care to 200 patients with alcohol use disorders. Tuberculosis providers performed screening for alcohol use disorders and also delivered naltrexone (with medical management) or a brief counseling intervention either independently or in combination as a seamless part of routine care. We report the innovations and challenges to intervention design, training, and delivery of both pharmacologic and behavioral alcohol interventions within programmatic tuberculosis treatment services. We also discuss the implications of these lessons learned within the context of meeting the challenge of providing evidence-based care in resource-limited settings.

Effective implementation of evidence-based interventions in “real-world” settings can be challenging. Interventions based on externally valid trial findings can be even more difficult to apply in resource-limited settings, given marked differences—in provider experience, patient population, and health systems—between those settings and the typical clinical trial environment. Under the auspices of the Integrated Management of Physician-Delivered Alcohol Care for Tuberculosis Patients (IMPACT) study, a randomized, controlled effectiveness trial, and as an integrated component of tuberculosis treatment in Tomsk, Russia, we adapted two proven alcohol interventions to the delivery of care to 200 patients with alcohol use disorders. Tuberculosis providers performed screening for alcohol use disorders and also delivered naltrexone (with medical management) or a brief counseling intervention either independently or in combination as a seamless part of routine care. We report the innovations and challenges to intervention design, training, and delivery of both pharmacologic and behavioral alcohol interventions within programmatic tuberculosis treatment services. We also discuss the implications of these lessons learned within the context of meeting the challenge of providing evidence-based care in resource-limited settings. (Harv Rev Psychiatry 2012;20:58–67.)

Study objective

This study compares the effect of a brief motivational intervention for alcohol plus a booster given to emergency department (ED) patients with subcritical injuries from a motor vehicle crash with the effect of brief motivational intervention for alcohol plus a booster in patients treated for non-motor vehicle crash-related injuries.

Methods

A randomized controlled trial (n=539) was conducted at an urban Level I trauma center of brief intervention (1 ED session of brief intervention), brief motivational intervention for alcohol plus a booster (1 ED session plus booster session), or standard care for injured ED patients with an alcohol use problem who were being discharged home. At 12 months, alcohol-related negative consequences and injuries were measured. We performed a secondary analysis comparing motor vehicle crash-injured patients and non-motor vehicle crash-injured patients in the study sample.

Results

Subcritically injured ED patients with harmful or hazardous alcohol use who received brief motivational intervention for alcohol plus a booster had fewer alcohol-related negative consequences and alcohol-related injuries than those receiving brief intervention or standard care at 12-month follow-up (previously reported). A secondary analysis of this result showed that motor vehicle crash patients (n=133) given brief motivational intervention for alcohol plus a booster (n=34) had fewer alcohol-related injuries than those receiving standard care (n=46; P=.001). Moreover, there were no significant differences in alcohol-related injuries among the non-motor vehicle crash-injured patients who received brief intervention or standard care.

Conclusion

Brief motivational intervention for alcohol plus a booster is a useful intervention for subcritically injured ED patients with harmful or hazardous alcohol use. Its effects may be moderated by the cause of injury. [Ann Emerg Med. 2005;45:620-625.]

Purpose

This study was designed to understand adolescent and parental perceptions, receptivity, and reactions to the concept of screening and brief intervention that primary care physicians can use to reduce alcohol consumption by their non-alcohol dependent adolescent patients.

Methods

A total of 6 nation-wide computer-assisted telephone focus groups were conducted; 3 with low-to-moderate risk for alcohol problems adolescents aged 15–17 years and 3 with parents of such adolescents.

Findings

Parents and adolescents held similar views on the prevalence and harms of adolescent alcohol consumption, but different levels of concern about them. After initial surprise and needed dispelling of misconceptions, all groups expressed interest, support, and suggestions for the concept of a physician-initiated, office-based intervention to address younger adolescent alcohol use.

Conclusions

Because both adolescents and parents of adolescents expressed interest in this type of intervention, physicians should be aware of this receptivity and consider focus group findings in how to structure development of a potential counseling-based intervention. Prior education about the target and nature of the intervention is necessary, lest adolescents and parents assume – incorrectly -- that it is about doctors preaching to high risk adolescents to stop drinking.

In a 2007 report, the US Surgeon General called for health care professionals to renew efforts to reduce underage drinking. Focusing on the adolescent patient, this review provides health care professionals with recommendations for alcohol-related screening, brief intervention, and referral to treatment. MEDLINE and published reviews were used to identify relevant literature. Several brief screening methods have been shown to effectively identify underage drinkers likely to have alcohol use disorders. After diagnostic assessment when germane, the initial intervention typically focuses on education, motivation for change, and consideration of treatment options. Internet-accessible resources providing effective brief interventions are available, along with supplemental suggestions for parents. Recent changes in federal and commercial insurance reimbursement policies provide some fiscal support for these services, although rate increases and expanded applicability may be required to prompt the participation of many practitioners. Nevertheless, advances in clinical methods and progress on reimbursement policies have made screening and brief intervention for underage drinking more feasible in general health care practice.