Primary care interventions for alcohol misuse: US Preventative Services Task Force recommendations
This post was written by Paul Christiansenfor the Mental Elf blog, you can find the original here
Alcohol misuse is recognised as one of the major health care issues in the US. Specifically, alcohol misuse is ranked third in causes of preventable deaths (after tobacco and obesity) affecting 30% of the population. Alcohol dependence has 4% prevalence in the US, but hazardous drinking patterns are believed to be evident in 21% of adults, contributing to a range of health concerns including gastritis, liver disease, pancreatitis and anxiety. In addition, 23% of 17 year olds reported at least one episode of heavy drinking in the previous fortnight. Significantly, heavy drinking is the major contributing factor to traffic accidents, the leading cause of death in US teenagers (Miniño, 2010).
Heavy drinking contributes to traffic accidents, which are the leading cause of death in US teenagers
The US Preventative Services Task Force (USPSTF) is an independent group of experts who make evidence-based recommendations about preventative services and interventions with the goal of improving the health of Americans. The current paper largely focuses on hazardous alcohol use which they define as drinking more than three (females) or four drinks (males) in a single session.
Their latest recommendations published here are specifically concerned with the efficacy of brief behavioural counselling interventions in primary care settings, and assessing which screening tests for alcohol misuse are most sensitive. Clear recommendations for adults are made although the authors conclude there is not sufficient evidence to recommend any primary care interventions for adolescents.
The USPSTF have based their recommendations on a review of treatment trials published between 1985 and 2011, and reviews and meta-analyses published between 2006 and 2011, which investigated behavioural counselling and screening procedures in adults, pregnant women and adolescents. Although this is largely a review article, there are also some statistics reported based upon meta-analysis of selected studies. The USPSTF specifically examined:
Direct evidence for the effectiveness and accuracy of screening instruments
The effectiveness of various brief behavioural counselling interventions for improving intermediate and long-term outcomes (23 trials)
Possible harms of these procedures
Among the screening instruments were many that readers will be familiar with, for example the Alcohol Use Disorders Identification Test (AUDIT), the AUDIT-Consumption (AUDIT-C; essentially the first three questions from the standard AUDIT). Other screening instruments investigated include single question methods e.g. “how many times in the previous year have you consumed over 5 drinks in one day?”, the Rapid Alcohol Problems Screen and Alcohol-Related Problems Survey.
Brief behavioural counselling strategies reviewed included face to face, telephone contact, online resources and self help manuals that include a range of cognitive-behavioural strategies such as action plans, stress management and problem solving. Counselling durations ranged from brief single contact (less than five minutes) up to extended multi contact (more than one session of over 15 minutes). Unfortunately the impact of different forms and durations of counselling were not specifically analysed, although an earlier systematic review (Jonas et al, 2012) in the same journal reported that the efficacy of counselling interventions improves with increased contact time.
This is what they found:
Brief behavioural counselling can reduce multiple indices of alcohol misuse, although the long term advantages are not clear
The AUDIT was the most sensitive screening tool with a 4+ cut off having the greatest sensitivity to alcohol misuse
AUDIT-C and single question screens were also found to be sensitive screening instruments
Meta-analysis of relevant studies revealed brief behavioural counselling significantly reduces binge drinking, total number of drinks per week, risky drinking patterns and incidents of exceeding recommended limits. Furthermore, there were no reported harms of the interventions
Significantly, meta-analysis of the nine trials that assessed long term outcomes found no evidence of significant improvement following brief behavioural counselling
Although found to be effective in both young and older adults, there was limited evidence for the efficacy of brief behavioural counselling in pregnant women and no evidence (due to a lack of research) on the efficacy of brief behavioural counselling in adolescents
The AUDIT is the most sensitive screening measure of alcohol misuse
Overall, brief behavioural counselling can reduce multiple indices of alcohol misuse, although the long term advantages are not clear
There is a severe lack of research investigating the impact of these interventions on adolescents
The authors concluded with these key recommendations:
The USPSTF recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioural counselling interventions to reduce alcohol
…the current evidence is insufficient to assess the balance of benefits and harms of screening and behavioural counselling interventions in primary care settings to reduce alcohol misuse in adolescents
This guidance highlights a lack of research investigating the impact of these interventions on young people
To summarise, this review indicates that any brief behavioural counselling interventions in primary care settings can improve short term alcohol outcomes in adults. Although it is notable that no recommendations were made in relation to adolescents due to the paucity of research.
Overall, this review offers some clarity to practitioners regarding the efficacy of brief behavioural counselling, although it does not make clear which forms of intervention (manual, telephone face-to-face) are most effective. The recommendation of the AUDIT as a screening tool adds to the large evidence base demonstrating this to be a reliable and sensitive instrument. Finally, the lack of recommendations for adolescents highlights the need for investigations into brief behavioural counselling in this population, if they are relatively cheap and effective in adults this indicates that they could be a useful clinical tool in adolescents.
The Elf would like to add a note of caution to experimental psychologists; the use of the 4+ cut off to define risky drinkers in a sample of UK undergraduates would probably lead to great difficulty in finding non-risk participants