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This entry is our account of a review or synthesis of research findings selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries are drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute this entry or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original review was not published by Findings; click on the Title to obtain copies. Links to source documents are in blue. Hover mouse over orange text for explanatory notes. The abstract is intended to summarise the findings and views expressed in the review. Below are some comments from Drug and Alcohol Findings.

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Brief interventions for heavy alcohol users admitted to general hospital wards.

McQueen J., Howe T.E., Allan L. et al.
Cochrane Database of Systematic Reviews: 2009, 3, Art. No. CD005191.

Heavy drinking hospital inpatients, many with alcohol-related disorders, ought to be prime candidates for advice on their drinking. But this synthesis of studies found impacts were often lacking; the jolt of a serious injury may have been the best platform for intervention.

Abstract Brief interventions are a time-limited intervention focused on changing behaviour, ranging from a few minutes of information and advice to up to three sessions of motivational interviewing or skills-based counselling involving feedback of assessment results. Risky drinkers among inpatients on hospital wards or in trauma centres are promising targets for brief interventions focused on drinking. These settings provide an opportunity to identify risky drinkers when they are accessible to health professionals, have time for an intervention, and can be made aware of any links between their hospitalisation and their drinking. Following a review supporting similar interventions in GPs' surgeries, this review aimed to assess whether they also reduce drinking and drink-related problems when conducted in hospital inpatient units.

A thorough search was conducted for studies which randomly allocated adult Aged 16 or over. patients to a brief intervention Of up to three sessions. versus no alcohol intervention Apart, of course, from being screened to identify them as heavy drinkers, plus any other research assessments, and in two studies a minimal intervention (leaflet or feedback on screening results). or usual care – or in some other way recruited an adequate comparison group – and then followed up the patients to see whether they had cut back on their drinking. Eligible studies were published in 2007 or earlier and concerned inpatients Except those admitted to units identified as psychiatric or addiction services. admitted to hospital not specifically for alcohol treatment, but who while there were identified as at risk due to their drinking. The search discovered 11 such studies involving 2441 participants. When possible Often it was not due to differences in measures. their results were amalgamated using meta-analysis. A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually.

Combined results from three studies which re-assessed patients six months later showed that on average those allocated to a brief intervention were drinking about 102g Nearly 13 UK units. However, later the review says that "Meta-analysis of 3 studies showed that compared to a control intervention brief intervention reduced the amount of alcohol consumed per week by 69 grams ... at 6 months follow up". less alcohol per week than comparison patients, a statistically significant difference unlikely to have occurred by chance. However, results varied across the studies. One which recorded a much greater difference than the other two featured several follow-up advice sessions, and the people assessing the outcomes knew who had been allocated to the brief intervention. Leaving out this study, brief intervention patients were still drinking 55g Nearly 7 UK units. a week less, but now the difference just fell short of statistical significance. Across two studies which re-assessed patients not six months but a year later, the combined 39g Nearly 5 UK units. reduction in alcohol consumption due to the intervention was not statistically significant.

These results were based on amounts being drunk at the follow-up assessment. Other studies enabled a similar analysis, but based on reductions in drinking from before to after the intervention. Across two studies which assessed patients at 12 months, the extra reduction in drinking due to intervention was statistically significant, but this was not the case in another two studies which re-assessed patients at six months. No other differences in indicators of drinking severity were statistically significant.

The analysts concluded that the benefits of delivering brief interventions to risky drinkers in hospital wards are inconclusive. It was, they thought, conceivable that inconsistent benefits might be due to the fact that simply screening and assessing patients had an impact of its own, which it was difficult for a further brief intervention to improve on. There was however a possibility (based on differences from baseline at six months versus one year) that drinking reductions were more persistent if screening had been supplemented by intervention.

For the reasons given The setting provides an opportunity to identify heavy drinkers when they are accessible to health professionals, have time for an intervention, and may be made aware of any links between their hospitalisation and their drinking. in the featured review, hospital inpatients seem promising candidates for alcohol interventions, yet the review found inconclusive evidence of an impact on their drinking over and above hospital admission and screening/assessment. The isolated positive findings related to drinking amounts at six months post-intervention and reductions from baseline drinking amounts at 12 months. Analysis of the five studies which underpinned these findings suggests that even these findings are questionable. The relevant issues are summarised below; for study-by-study details see background notes.

Of the three studies responsible for the six-month finding, in two there was considerable doubt over whether the drinking reductions resulted from what is normally thought of as a brief intervention. Conducted in Finland, one of these studies recorded an unusually large impact when patients seriously injured (we can fairly assume) as a result of their heavy drinking were repeatedly counselled by a nurse and their doctors. In the third study, a positive contribution to the finding that brief interventions were effective would have been negative had another intervention variant tested in the study been selected for the analysis. In two of the studies, the degree of loss to follow-up, or its imbalance across intervention and control groups, raise concerns over the reliability of the findings or their generalisability to heavy drinking patients in general.

The finding of a significant impact on drinking at 12 months was based on a greater reduction between the pre-intervention assessment and the repeat assessment 12 months later across two US studies. In both, only a minority of risky drinking patients on the wards contributed follow-up data, raising questions over the generalisability of the findings to risky drinking patients in general. By far the most convincing of these studies was conducted on a ward dealing with serious injuries and among patients whose injuries warranted at least a 24-hour stay. Its finding of much greater drinking reductions after intervention than after assessment and usual care may have been biased by the fact that many more of the intervention group had elevated blood alcohol levels. In turn this means many more were likely to have been admitted with a clearly alcohol-related injury, giving them extra motivation regardless of the intervention. The second study, of general medical inpatients, found only minor and statistically insignificant extra reductions in drinking after intervention.

It may be no coincidence that the two studies which recorded the greatest impacts at six and 12 months respectively concerned patients admitted due to serious injuries rather than illnesses; As opposed to patients injured due to intoxication, it could be that for patients with chronic alcohol-related illnesses the dangers of their drinking are either less obvious and convincing, or if obvious, have previously been rehearsed several times by their doctors. In pointing out the dangers, or encouraging the patients to reflect on them, brief interventions might add little to what they already know or to the influences already brought to bear on them. in both it seems virtually certain that many had been injured as a result of fairly extreme drinking. The interventions in these studies were well placed to build on this salutary experience.

However, hindsight rationalisation of why some studies recorded an impact, but others none or a minor one, can only be speculative. The certain conclusion is that impacts on drinking can happen, but are inconsistent and often lacking. Given the nature of the studies, it is also unclear whether such impacts as there were would be replicated in normal practice. All these verdicts are based on overall drinking amounts; if patients had been prompted to manage their drinking better, alcohol-related harm or potential harm resulting from injuries while intoxicated might have been reduced, even if drinking amounts remained unchanged. In the three studies which took relevant measures, this was substantially Though in study 1 the differences were not statistically significant. the case in two (1 2), but not in the third.

Such results give little to reason to rely on hospital inpatient settings for reducing drinking and related problems through brief interventions. On the other hand, such interventions can reduce drinking, and in some studies substantially reduced risk or harm. Since very brief and unsophisticated interventions often work as well as longer ones, even if the pay-off is uncertain, the required investment is minimal. Also the study excluded a model Findings is grateful to James Morris of the AERC Alcohol Academy (www.alcoholacademy.net) for pointing this out. being implemented in some British hospitals which links risky drinking patients to services in the community rather than (or as well as) conducting a brief intervention on the ward. The few formal studies of this approach (1 2) have had at best mixed results, though on the ground (for example in Liverpool) some success has been noted.

Current alcohol screening policy in England and Scotland focuses more on primary care and accident and emergency departments than general hospitals, but the Department of Health's programme of improvement for alcohol misuse interventions saw hospitals as one of the sites for such work, particularly clinics dealing with complaints often related to drinking. In the Welsh national alcohol/drug strategy, accident and emergency departments are the only specific hospital units singled out as a venue for brief interventions. The equivalent document for Northern Ireland makes no mention of brief interventions in hospitals.

Though aimed at other medical settings, practical guidance on alcohol brief interventions is available from a UK web site developed by leading researchers and in an officially published US guide from the American College of Surgeons.

Thanks for their comments on this entry to Jean McQueen of the Ayr Clinic, Partnerships in Care, Scotland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 August 2009
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