The Impact of Brief Alcohol Interventions in Primary Care
The Impact of Brief Alcohol Interventions in Primary Care
Aims: The aim of the study was to assess the cumulative evidence on the effectiveness of brief alcohol interventions in primary healthcare in order to highlight key knowledge gaps for further research.
Methods: An overview of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare published between 2002 and 2012.
Findings: Twenty-four systematic reviews met the eligibility criteria (covering a total of 56 randomized controlled trials reported across 80 papers). Across the included studies, it was consistently reported that brief intervention was effective for addressing hazardous and harmful drinking in primary healthcare, particularly in middle-aged, male drinkers. Evidence gaps included: brief intervention effectiveness in key groups (women, older and younger drinkers, minority ethnic groups, dependent/co-morbid drinkers and those living in transitional and developing countries); and the optimum brief intervention length and frequency to maintain longer-term effectiveness.
Conclusion: This overview highlights the large volume of primarily positive evidence supporting brief alcohol intervention effects as well as some unanswered questions with regards to the effectiveness of brief alcohol intervention across different cultural settings and in specific population groups, and in respect of the optimum content of brief interventions that might benefit from further research.
A range of interventions exist for the prevention and treatment of alcohol-related risk and harm, from health-promoting input aiming at reducing hazardous and harmful drinking, to more intensive and specialist treatment for severely dependent drinking. Primary healthcare is seen as an ideal context for the early detection and secondary prevention of alcohol-related problems, due to its high contact-exposure to the population (Lock et al., 2009), and the frequency with which higher-risk drinkers present (Anderson, 1985).
In particular, screening and brief intervention for alcohol has emerged as a cost-effective preventative approach (Hutubessy et al., 2003), which is relevant and practicable for delivery in primary healthcare (Raistrick et al., 2006), where patients tend to present with less acute conditions, return regularly for follow-up appointments (Bernstein et al., 2009) and build long-term relationships with their GP (Lock, 2004). These interventions are typically short in duration (5–25 min), designed to promote awareness of the negative effects of drinking and to motivate positive behaviour change (HoC Health Committee, 2010).
Despite considerable efforts over the years to persuade practitioners to adopt brief interventions in practice, most have yet to do so. Indeed, there is an international literature on barriers to brief alcohol intervention (Heather, 1996; Kaner et al., 1999; Babor and Higgins-Biddle, 2000; Aalto et al., 2003; Aira et al., 2003; Wilson et al., 2011), the majority focussing on primary healthcare. These barriers include: lack of time, training and resources; a belief that patients will not take advice to change drinking behaviour; and a fear amongst practitioners of offending patients by discussing alcohol. It has therefore been argued that today's challenge is more about how to encourage the uptake and use of brief alcohol intervention in routine practice (Anderson et al. 2004; Nilsen et al., 2006; Johnson et al., 2010; Kaner, 2010a; Gual and Sabadini 2011), and less about financing additional research on its effectiveness. It would seem timely, therefore, to evaluate the extent to which the primary healthcare brief alcohol intervention evidence base is now saturated, or whether there are any remaining knowledge gaps requiring further investigation.
This paper reports on the EU co-funded research BISTAIRS (brief interventions in the treatment of alcohol use disorders in relevant settings) project, which aims to intensify the implementation of brief alcohol intervention by identifying, systematizing and extending evidence-based good practice across Europe. Given the existence of several reviews in this field, and the overarching BISTAIRS timescale, the first phase of the project comprised a systematic overview of published reviews to provide a structured, comprehensive summary of the evidence base on the effectiveness of brief alcohol intervention in primary healthcare.
The focus on effectiveness (how an intervention performs in real world conditions) as opposed to efficacy (how an intervention performs under optimal or ideal world conditions) is deliberate. There is a well-established literature on the distinction between efficacy and effectiveness trials (Flay, 1986), although the terms explanatory or pragmatic trials are sometimes also used (Thorpe et al., 2009). However, placing trials into one category or other is challenging since there is wide agreement that they actually sit on a continuum from optimized to naturalistic conditions (Gartlehner et al., 2006). Moreover, efficacy must be demonstrated before effectiveness is assessed and the latter is a necessary pre-condition for wider dissemination (Flay et al., 2005). The US Society for Prevention Research (Flay et al., 2004, 2005) has outlined that efficacy testing requires at least two rigorous trials involving: tightly defined populations; psychometrically sound measures and data collection procedures; rigorous statistical analysis; consistent positive effects (without adverse effects); and at least one significant long-term follow-up. This requirement has been comprehensively established in a field where over 60 high-quality brief intervention trials have been reported in peer-reviewed journals, with over half based in primary healthcare (Kaner, 2010b).
This paper focuses on effectiveness, adding clinical breadth to methodological rigour by: extending the range of patients and delivery agents in trials; specifying details of necessary training and technical support; clarifying the nature of comparison or control conditions; assessing intervention fidelity; and conducting unbiased (generally intention to treat) analyses, which also considers effects on different sub-groups of patients and differing outcome exposures (Flay et al., 2005; Thorpe et al., 2009). To add to the brief alcohol intervention literature, we synthesize the findings from a rapidly growing number of systematic reviews to answer four questions: (a) does the cumulative evidence base continue to show that brief alcohol intervention is effective when delivered in primary healthcare settings? (b) is brief alcohol intervention equally effective across different countries and different healthcare systems? (c) is the brief alcohol intervention evidence base applicable across different population groups? and (d) what is the optimum length, frequency and content of brief alcohol intervention, and for how long is it effective?
Abstract and Introduction
Abstract
Aims: The aim of the study was to assess the cumulative evidence on the effectiveness of brief alcohol interventions in primary healthcare in order to highlight key knowledge gaps for further research.
Methods: An overview of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare published between 2002 and 2012.
Findings: Twenty-four systematic reviews met the eligibility criteria (covering a total of 56 randomized controlled trials reported across 80 papers). Across the included studies, it was consistently reported that brief intervention was effective for addressing hazardous and harmful drinking in primary healthcare, particularly in middle-aged, male drinkers. Evidence gaps included: brief intervention effectiveness in key groups (women, older and younger drinkers, minority ethnic groups, dependent/co-morbid drinkers and those living in transitional and developing countries); and the optimum brief intervention length and frequency to maintain longer-term effectiveness.
Conclusion: This overview highlights the large volume of primarily positive evidence supporting brief alcohol intervention effects as well as some unanswered questions with regards to the effectiveness of brief alcohol intervention across different cultural settings and in specific population groups, and in respect of the optimum content of brief interventions that might benefit from further research.
Introduction
A range of interventions exist for the prevention and treatment of alcohol-related risk and harm, from health-promoting input aiming at reducing hazardous and harmful drinking, to more intensive and specialist treatment for severely dependent drinking. Primary healthcare is seen as an ideal context for the early detection and secondary prevention of alcohol-related problems, due to its high contact-exposure to the population (Lock et al., 2009), and the frequency with which higher-risk drinkers present (Anderson, 1985).
In particular, screening and brief intervention for alcohol has emerged as a cost-effective preventative approach (Hutubessy et al., 2003), which is relevant and practicable for delivery in primary healthcare (Raistrick et al., 2006), where patients tend to present with less acute conditions, return regularly for follow-up appointments (Bernstein et al., 2009) and build long-term relationships with their GP (Lock, 2004). These interventions are typically short in duration (5–25 min), designed to promote awareness of the negative effects of drinking and to motivate positive behaviour change (HoC Health Committee, 2010).
Despite considerable efforts over the years to persuade practitioners to adopt brief interventions in practice, most have yet to do so. Indeed, there is an international literature on barriers to brief alcohol intervention (Heather, 1996; Kaner et al., 1999; Babor and Higgins-Biddle, 2000; Aalto et al., 2003; Aira et al., 2003; Wilson et al., 2011), the majority focussing on primary healthcare. These barriers include: lack of time, training and resources; a belief that patients will not take advice to change drinking behaviour; and a fear amongst practitioners of offending patients by discussing alcohol. It has therefore been argued that today's challenge is more about how to encourage the uptake and use of brief alcohol intervention in routine practice (Anderson et al. 2004; Nilsen et al., 2006; Johnson et al., 2010; Kaner, 2010a; Gual and Sabadini 2011), and less about financing additional research on its effectiveness. It would seem timely, therefore, to evaluate the extent to which the primary healthcare brief alcohol intervention evidence base is now saturated, or whether there are any remaining knowledge gaps requiring further investigation.
This paper reports on the EU co-funded research BISTAIRS (brief interventions in the treatment of alcohol use disorders in relevant settings) project, which aims to intensify the implementation of brief alcohol intervention by identifying, systematizing and extending evidence-based good practice across Europe. Given the existence of several reviews in this field, and the overarching BISTAIRS timescale, the first phase of the project comprised a systematic overview of published reviews to provide a structured, comprehensive summary of the evidence base on the effectiveness of brief alcohol intervention in primary healthcare.
The focus on effectiveness (how an intervention performs in real world conditions) as opposed to efficacy (how an intervention performs under optimal or ideal world conditions) is deliberate. There is a well-established literature on the distinction between efficacy and effectiveness trials (Flay, 1986), although the terms explanatory or pragmatic trials are sometimes also used (Thorpe et al., 2009). However, placing trials into one category or other is challenging since there is wide agreement that they actually sit on a continuum from optimized to naturalistic conditions (Gartlehner et al., 2006). Moreover, efficacy must be demonstrated before effectiveness is assessed and the latter is a necessary pre-condition for wider dissemination (Flay et al., 2005). The US Society for Prevention Research (Flay et al., 2004, 2005) has outlined that efficacy testing requires at least two rigorous trials involving: tightly defined populations; psychometrically sound measures and data collection procedures; rigorous statistical analysis; consistent positive effects (without adverse effects); and at least one significant long-term follow-up. This requirement has been comprehensively established in a field where over 60 high-quality brief intervention trials have been reported in peer-reviewed journals, with over half based in primary healthcare (Kaner, 2010b).
This paper focuses on effectiveness, adding clinical breadth to methodological rigour by: extending the range of patients and delivery agents in trials; specifying details of necessary training and technical support; clarifying the nature of comparison or control conditions; assessing intervention fidelity; and conducting unbiased (generally intention to treat) analyses, which also considers effects on different sub-groups of patients and differing outcome exposures (Flay et al., 2005; Thorpe et al., 2009). To add to the brief alcohol intervention literature, we synthesize the findings from a rapidly growing number of systematic reviews to answer four questions: (a) does the cumulative evidence base continue to show that brief alcohol intervention is effective when delivered in primary healthcare settings? (b) is brief alcohol intervention equally effective across different countries and different healthcare systems? (c) is the brief alcohol intervention evidence base applicable across different population groups? and (d) what is the optimum length, frequency and content of brief alcohol intervention, and for how long is it effective?
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