Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 5 December 2011

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents

The power of brief interventions

Three of the four entries in this bulletin bear further testimony to the power of brief interventions and therapies, the fourth to the general impotence of anti-drug campaigns. For classic British studies on brief interventions, see this Findings review.

Even dependent drinkers respond well to alcohol brief interventions ...

Alcohol brief interventions: doing without the doctor ...

Lasting relief for partners and parents coping with addiction in the family ...

Anti-drug ads do not work and can be counterproductive ...


Brief interventions in dependent drinkers: a comparative prospective analysis in two hospitals.

Cobain K., Owens L., Kolamunnage-Dona R. et al.
Alcohol and Alcoholism: 2011, 46(4), p. 434–440.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Owens at lynno@liv.ac.uk. You could also try this alternative source.

In the north of England just a few (and often just one) counselling sessions by a specialist nurse had a remarkable impact on dependent drinkers seeking medical care at an accident and emergency department.

Summary Unusually this study in England's north west region assessed the impact of relatively brief advice, not on adult drinkers selected to be at risk from their drinking, but those likely already to be dependent. As with studies of non-dependent drinkers, despite their heavy drinking they were not seeking treatment for drink problems but attending a hospital accident and emergency department for some other reason.

Patients whose attendance was thought to be related to drinking were referred for assessment to specialist hospital or research nurses by emergency department triage staff in two hospitals in neighbouring cities. The assessments included the AUDIT questionnaire and for patients who scored as possibly dependent, the Severity of Alcohol Dependence Questionnaire. Patients indicated by both to possibly be at least mildly dependent were asked to join the study.

In Liverpool the assessments were done by specialist alcohol nurses who immediately engaged possibly dependent patients in about 20 minutes of advice based on the FRAMES model, Feedback (on the client's risk of having alcohol problems), responsibility (change is the client's responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change). prioritising exploration of patients' perceptions of the link between their drinking and their hospital attendance. At the nurses' and patients' discretion, further sessions could be arranged. In practice, of the 100 patients recruited to the study, 46 attended typically four further sessions. In the other hospital in nearby Warrington, the same referral and research recruitment procedures operated, but instead patients were referred to a nurse who was part of the research team who did not offer any alcohol-related advice. Again, 100 patients were recruited at this site to act as a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group against which to benchmark any improvements associated with counselling.

At both sites most patients were daily drinkers who consumed on average about 27 UK units (216g) of alcohol a day, tested as severely dependent, and were taking alcohol withdrawal medication. Typically they were single, unemployed white men in their mid-40s suffering from gastrointestinal or cardiovascular complaints. Six months later research nurses were able to reassess about half the patients to evaluate changed in their drinking and drink-related problems since they joined the study.

Main findings

% of patients with different severities of alcohol dependence at six-month follow-up

Six months later the general picture was (despite some reductions) of continued severe drinking and drink-related problems in the control group, but substantial remission among patients who had been counselled by specialist alcohol nurses. The controls were still drinking on average 23 units (184g) of alcohol on nearly six days a week, while counselled patients had cut back to nearly four days a week and eight units (64g). These averages reflected the fact that none of the controls but 39% of the counselled patients had stopped drinking altogether. Also, just 17% of the counselled patients scored as severely dependent on the Severity of Alcohol Dependence Questionnaire compared to 56% of the controls chart. The greater reductions in drinking days and intensity and in scores on the two alcohol problem questionnaires were all highly statistically significant.

Not statistically significant but almost so was the difference in the times patients returned to accident and emergency departments – about 90 times among the 50 control patients but only 34 times (or 36 extrapolated to 50 patients) among those counselled.

The authors' conclusions

The study demonstrates that treatment can be accepted and effective among dependent drinkers who have not come seeking treatment for their drinking. Generally it has not been ethically acceptable to deny treatment to dependent drinkers who are seeking it, complicating the evaluation of whether treatment works. In contrast, because patients were not seeking or expecting treatment, this study was able to compare structured treatment with no specific treatment. It showed that treatment is effective, and that even severely dependent patients can substantially benefit from relatively brief treatment. The patients in this study were usually medically ill; providing alcohol treatment in a general hospital offers a way to reach them even if they do not present to alcohol treatment clinics, and may reduce their need for further medical care.

The greater drinking reductions among patients at the hospital offering counselling were due to the greater abstinence rate – 39% v. 0%. It seems likely that their medical conditions would have mandated advice to abstain for 8 in 10 patients and that this was the advice given by the specialist nurses, advice often well responded to. From previous research, it seems likely that planned follow-up counselling augmented the impact of the evaluated intervention.

Though striking, the results have emerged from a study in which patients were not randomly allocated and attended different hospitals. On the assessed variables, the patients seemed similar but there may have been remaining differences between them and between how they were treated at the hospitals which contributed to the findings. Moreover, the research nurse who conducted the follow-up assessments was not always 'blinded' to whether patients had been counselled. Despite its general brevity, it is a moot point whether the open-ended treatment could be called a 'brief intervention'. Half the patients could not followed up, potentially biasing the findings.


Findings logo commentary It is a moot point whether this was a test of a brief intervention or of a usually not very long treatment. Nearly half the patients attended not just the initial session but four more, exceeding in sessions the number offered as motivational therapy to patients in the British UKATT alcohol treatment trial. British specialists have argued that multi-session therapies offered by appointment with alcohol specialists are really brief treatment, even if the patient was not originally attending for alcohol treatment. Such therapies are increasingly commonly offered to patients seeking treatment and those identified in the course of other medical consultations, yet are rarely recorded as adding to alcohol treatment nationally.

However termed, the critical factor in the featured study was that these patients were not seeking help with their drinking yet were able to accept and benefit from that help. Impressive results are weakened somewhat by the low follow-up rate. But even if we assume bad outcomes (severe alcohol dependence, death or imprisonment) in all patients not followed up, at most 60% of the counselled patients met these fates compared to 88% not counselled. Similarly, assuming continued drinking among patients not re-assessed, the abstinence rate would be 19% among counselled patients but zero among those not counselled. Yet on average these patients drank at least as much as those at specialist alcohol clinics in the UKATT trial in England and Wales, who were seeking treatment and offered what was intended to be a full course Though in the case of the motivational intervention, only three sessions. of psychosocial therapy in addition to medical treatments like detoxification and anti-relapse medications. In that study, 12 months after starting treatment a minimum of 12% Table 1 of the original report indicates that 26 + 65 had sustained abstinence of the 742 who started the study. of patients had sustained abstinence over the past three months, compared to 19% at six months (over an unspecified period) in the featured study.

Despite its successes, for most patients the intervention was not enough. If abstinence is the yardstick of success, 8 in 10 could not be shown Assuming those who could not be followed up and the two who died were not abstinent. to have achieved it; if not being severely dependent was the yardstick, the corresponding proportion was 6 in 10. Whether more extended or intensive intervention would have been accepted by the patients and helped reduce the failure rate is unclear. The main limitation on delivering it might have been staying in touch with the patients. Few were homeless, yet two letters and two phone calls were unable to recall half for follow-up assessments.

As the authors speculated, it could be that the nurses and perhaps ward staff were in a position in most cases to credibly counsel abstinence on medical grounds, helping bolster the results. Few patients were there because of injuries which could be avoided by continuing to drink but taking greater care to avoid getting drunk in dangerous situations. Instead, most seemed to be suffering from chronic conditions which would be aggravated by continued drinking. They were also generally the type of people While insufficient to determine individual treatment, research does indicate that in general successful non-abstinent outcomes are associated with younger and female patients, those who are relatively socially integrated and psychologically stable, less severely alcohol dependent, and who strongly believe in their ability to moderate their drinking. research suggests are most receptive to abstinence as a goal of treatment and least able to sustain non-problem drinking.

Among the issues raised by the study are whether extended treatment is always required before dependent patients – especially those with the disadvantages shared by most of the study's sample – can attain non-dependent drinking or abstinence. Along with other research, it clearly indicates that this is not the case for many patients. More generally, added benefits from longer versus shorter treatments (as opposed to post-treatment aftercare) has yet to be adequately established. Another issue is whether brief interventions will only benefit non-dependent patients. Again this study along with other research strongly suggests this is not always (but sometimes) the case. What makes the difference may be whether the patient makes (or can be led to make) a link between their drinking and the medical misfortune which led them to the emergency department. These issues are explored in greater detail in the background notes.

Perhaps the most serious of the limitations acknowledged by the authors is that the hospitals may have differed not just in the availability of specialist alcohol counselling, but in how drinking was addressed by other medical staff. With counsellors available to handle the aftermath, in Liverpool they may have been more willing to expose the need for counselling by assessing and discussing alcohol problems with their patients. A hospital which hosts four specialist alcohol nurses is likely to have a different and perhaps more serious attitude to drinking than one which hosts none. But even if this were the case, it would not affect the strength of the intervention's impact, just relocate a greater part of that intervention to usual medical staff.

British studies

In 2008 an audit of alcohol health service provision in England found that advice-giving at accident and emergency departments was rare. Commissioners have reportedly found it hard to persuade staff to undertake this work.

The best researched example is the programme at St. Mary's hospital in London, which uses trained and motivated (performance feedback is important) emergency unit staff to screen suspected heavy drinkers or patients with complaints linked to heavy drinking. Doctors explain to positive screen patients that drinking is damaging their health and offer an appointment with an on-site health worker, typically the same or the next working day. In these circumstances, two-thirds of patients attend for advice. Offering this service was found to reduce later drinking and return visits to the department. Further analysis based on the same study found that total public service costs and productivity losses over the following 12 months were roughly equivalent whether or not the intervention was offered, but that offering it was the most cost-effective option for reducing drinking. Another study at the unit demonstrated the (at least temporary) feasibility of tasking reception staff to hand out screening questionnaires to all adult ambulant patients, and the willingness of over half the patients to fill in and return the forms.

Among other policy drivers, the recent national focus on reducing alcohol-related hospital admissions, and recognition of hospital-based alcohol specialists as a priority by the Department of Health, has helped stimulate emergency department brief intervention initiatives, some of which have been reported on. For example, in implementation terms, a major programme in Manchester started in late 2006 was a limited success – generally accepted by staff and patients, but at some sites falling well below anticipated screening rates, and only a few of the patients offered this attended for more extended alcohol advice from a specialist nurse. However, experience at the hospitals showed that screening rates could be improved by feeding back to and rewarding staff, and making the recording of screening decisions and results mandatory. A report on the early months of operation at one of the sites reveals how few patients were counselled beyond any advice given during screening: of about 27,000 people screened over 10 months, just 99 – a tiny fraction of the anticipated at-need population.

That a successful screening and intervention programme can take over a year to develop was the implication of a report on a project in a Basingstoke hospital. The targeted 100 interventions per month across the hospital including the emergency department materialised in the first year as just 42 involving 20 people per month.

The featured study's model of a specialist nurse to whom patients can be referred for brief advice is common in the UK. It relieves general hospital staff of this burden and encourages screening because this does not entail the 'risk' that the clinician will have to engage in counselling positive-screen patients. However, commonly such nurses have multiple roles. When the national charity Alcohol Concern investigated this model at eight locations in England, it found that often screening and brief intervention had entirely or largely given way to managing dependent patients through detoxification and treatment.

The Scottish drive to implement alcohol brief interventions in emergency care and other settings from April 2008 seems to have been most successful in GPs' surgeries. In the three health board areas where these figures were known, 17%, 8% and not more than 7% of interventions were delivered in emergency departments. If these kind of figures applied nationally, these departments accounted for perhaps 11% of the 174,205 alcohol brief interventions recorded over the three years, or about 6400 a year – just over 6% of the estimated 100,000 alcohol-related attendances per year to Scottish emergency departments. Why this might be was revealed by staff interviews conducted as part of a national evaluation. Resistance from staff (feeling that this was not their business and detracted from core activities and objectives) and time pressures sometimes led (contrary to the preferred option in guidance) to intervention being by appointment some time after screening rather than immediate, and this in turn reduced attendance. Screening rates probably too suffered from inadequate buy-in by staff, but might have suffered more had they had to cater for the possibility that a positive screen would mean they had to spend more precious minutes counselling the patient.

For more on emergency department brief intervention initiatives run this search on the Alcohol Learning Centre site.

The UK policy climate

In England directors of public health are expected to include alcohol brief interventions among attempts to address the population-wide determinants of ill health. This policy is in line with recommendations from Britain's National Institute for Health and Clinical Excellence (NICE), which in 2010 saw screening and brief interventions targeted at risky drinkers as an effective way to prevent drinking problems, though one less important at a population level than policy changes affecting the price and availability of alcohol. Among the sites NICE envisaged for this work were emergency departments, and the recommended approach was the FRAMES model Feedback (on the client's risk of having alcohol problems), responsibility (change is the client's responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change). trialled in the featured study. However, the guidance acknowledged that (in contrast to primary care) research on emergency department interventions was scarce and the barriers to implementation were considerable.

In Scotland national policy prioritises screening and brief intervention in primary care, antenatal care, and accident and emergency departments, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions across the three years supported by dedicated funding. Set in the context of what was in any event 111,200 primary care consultations for alcohol misuse in a single year in 2006/07, this target of around 50,000 a year across all three priority settings may seem to lack ambition. It was set on the basis that 19% of adult patients would present to these services with conditions possibly related to drinking, that all would be screened for excessive drinking and a fifth would screen positive. The target was to actually counsel three quarters of these at-need patients. In the event, the target was exceeded; over the three-year period 174,205 alcohol brief interventions were recorded across the three priority settings.

The Welsh substance misuse strategy recognises the potential value of brief alcohol interventions in accident and emergency departments, but its action plan made no commitment to their expansion; neither did the strategy for Northern Ireland.

However, on the basis of encouraging pilot results, in February 2012 the Welsh government committed to nationwide implementation of alcohol screening and brief intervention in emergency departments. Areas in England too have made a similar commitment. The decision has been taken to extend such services across Birmingham's emergency departments and elsewhere in the West Midlands, while, concerned about the rising number of drink-related hospital admissions, health managers in Greater Manchester plan to implement widespread screening in emergency departments and to fund specialist alcohol nurses to handle the resultant counselling. It is unclear whether these are isolated 'bright spots', or in England local initiatives cumulative to a national implementation drive to match that in Scotland and being planned Wales.

In the UK advice on brief interventions is available from the Alcohol Learning Centre, while for Scotland specific guidance has been published for emergency department staff. US guidance is available on the SBIRT method trialled nationally and on emergency department alcohol screening and intervention in general.

Thanks for their comments on this entry in draft to Don Lavoie of the Alcohol Policy Team at the UK Department of Health. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 18 February 2012

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STUDY 2014 The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

STUDY 2014 A multisite randomized controlled trial of brief intervention to reduce drinking in the trauma care setting: how brief is brief?

STUDY 2010 The impact of screening, brief intervention and referral for treatment in emergency department patients' alcohol use: a 3-, 6- and 12-month follow-up

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STUDY 2012 Alcohol screening and brief intervention in primary health care

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A meta-analysis of the efficacy of nonphysician brief interventions for unhealthy alcohol use: implications for the patient-centered medical home.

Sullivan L.E., Tetrault J.M., Braithwaite R.S. et al.
American Journal on Addictions: 2011, 20, p. 343–356.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Sullivan at lynn.sullivan@yale.edu.

It works when the doctor does it, but what if the nurse or other primary care staff counsel risky drinking patients? It still works – maybe not as well, but perhaps more patients can be reached more cheaply.

Summary Recent reviews have concluded that brief interventions conducted by doctors result in significant declines in drinking compared to not offering such advice. This evidence supports clinicians spending time delivering brief alcohol interventions and they are encouraged and reimbursed to do so by national authorities. Yet doctors provide these interventions infrequently and time constraints limit attention to this important health issue. One way forward would be for health care staff other than doctors (such as a nurses, doctors' assistants, health educators, or psychologists) to deliver these interventions, raising the issue of whether they would be equally effective.

To address this issue, the featured review identified studies published in English up to 2008 of brief, structured alcohol counselling by non-physician medical staff (with or without additional input from doctors) in primary care clinics, which reported on drinking outcomes compared to not offering such counselling. The analysis allowed for the possibility that impacts might vary in the different circumstances investigated by the trials.

A search uncovered 13 relevant studies, all but two of which included interventions delivered solely by non-physician staff. The comparator was 'usual care' – generally very brief advice either from a physician or a non-physician clinician. Patients offered these interventions had generally been identified as harmful or hazardous drinkers.

Main findings

Seven studies with 2210 patients provided sufficient information for their findings to be pooled statistically by meta-analysis. A study which uses recognised procedures to combine 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. Across these studies, compared to usual care, a structured brief intervention by non-physician staff on average further reduced drinking 24g (3 UK units) per week. The extra reduction was not significantly different depending on how severe the average patient's drinking was in the different studies.

One study was (according to criteria set when the review was planned) an 'outlier' which, due to an unusually strong intervention impact, disproportionately contributed to the variation in impact across the seven studies. Excluding this study slightly reduced the average intervention impact to 20g alcohol or about two and a half UK units a week.

Three of the 13 studies included a comparison between the effectiveness of interventions delivered by non-physician medical staff versus doctors and found no statistically significant differences in the degree to which patients cut down their drinking – direct evidence that non-physician clinicians can be as effective as doctors. In one of the two studies to examine this scenario, adding non-physician inputs to those of doctors created lasting and statistically significant extra reductions in drinking.

The authors' conclusions

This systematic review and meta-analysis offers preliminary support for the benefit of brief interventions for unhealthy alcohol use conducted by non-physician staff in primary care settings, either alone or in combination with physicians. When directly compared, non-physician-based interventions were no less effective than physician-based interventions, and can effectively supplement the latter. The pooled impact of the interventions was lower (24g v. 38g less alcohol drunk per week) than found for interventions conducted by clinicians, but the difference was not statistically significant.

However, making practice recommendations based on these studies is complicated by the fact that the interventions varied from a single five-minute session to six 90-minute sessions, beyond the limit normally considered 'brief'. At best the studies were of fair quality, raising concerns about the overall quality of the results and the legitimacy of translating these findings into a real-world model. Also the variations in their methodologies raise concerns over whether it was meaningful to pool their results.

The featured review is consistent from evidence in respect of other behavioural and mental health problems managed in primary care such as depression and smoking, when non-physician staff have been shown to be effective.


Findings logo commentary The modest average reduction in drinking and the cautions expressed by the analysts mean concerns over whether clinically significant reductions would be replicated in usual practice must be taken seriously. Evidence from the featured review and other work shows that primary care medical staff can deliver brief counselling which reduces drinking among risky drinking patients. A remaining major challenge is how to consistently realise that potential – how to turn 'can' into 'do'. There remains considerable doubt over whether the average drinking reduction seen in trials will be replicated if intervention is 'scaled up' to practices in general, and applied by the general run of primary care staff to the general run of patients. This is partly a doubt over the consistency of the effectiveness of systematic screening and structured intervention compared to usual practice, partly over whether studies have been sufficiently representative of normal practice, and partly over whether this degree of systematisation will be widely implemented. Where the climate is supportive, organisational and personal incentives are strong, and performance against targets matters and is monitored, implementation rates can be high; in other circumstances, they can be near zero. The few British studies of non-doctor primary care alcohol interventions give some – but far from convincing – evidence that these reduce drinking, and found that in practice few patients were screened and advised. Details below.

One finding in the review could be misunderstood to imply that supplementing the doctor's counselling with that from non-physician staff had been found in one study to significantly improve drinking outcomes. In fact that study (1 2 3) tested a single intervention variously delivered by nurses and doctors who were aided by administrative support from research assistants. The assistants attached to the patient's notes information from research assessments of their drinking, the intervention guide, and patient education materials, prompting primary care staff to intervene as intended with the patient. This package was compared against usual care which rarely involved any alcohol counselling at all, and again was variously delivered by nurses and doctors. Apart from the outlier study, this was the single most convincing demonstration of the impact of 'non-doctor' intervention, being considered at least of fair quality and registering the largest effect. However, 22 of the 27 interventionists were doctors and the study was conducted at just four primary care clinics managed by a single US health provider of which two were adjacent so were considered a single unit.

UK studies

The government-funded SIPS national trial of brief alcohol interventions in England included a primary care arm which involved practice nurses as well as GPs in screening and counselling. The largest such trial to date, it found that given financial incentives, training and specialist support, most primary health care practices could implement screening and intervention, but in the circumstances at least of a research trial, they screened and advised few of their patients; on average, less than two per GP practice per week. Least well implemented was the longest of the three interventions tested, which required appointments to be made and kept, rather than seamless delivery of briefer interventions during the patient's initial attendance. But implementation problems did not seem to account for why the anticipated extra benefits of the longer and more sophisticated, theory-based interventions did not materialise, even It seems from preliminary reports. for heavier drinkers, leaving the shortest and simplest intervention looking the most cost-effective – an alcohol advice booklet plus a few sentences of feedback alerting someone to their risky drinking. These findings cast doubt over the potential for primary care screening and brief intervention to make a significant contribution to public health; numbers reached may simply be too low.

Before SIPS the main studies of non-physician alcohol interventions in British primary care surgeries derived from the early 2000s in the north east of England. Like SIPS, they gave some – but far from convincing – evidence that these interventions reduce drinking among risky drinkers, and suggested that under the conditions at the time, few patients are screened and advised. Details below.

One study conducted in the early 2000s in England's north east region tested whether an intervention delivered by nurses in 49 practices (of 273 invited to join the study) reduced drinking. The nurses were asked to opportunistically (ie, at their discretion as the opportunity presented itself) screen patients for risky drinking using the few questions in the AUDIT questionnaire. Practices were randomly allocated to counsel those who scored as risky drinkers using the brief intervention protocol being evaluated, or the nurse's usual response. During the study, nurses approached on average 10 patients each for screening, of whom about a quarter (127 patients) were AUDIT-positive and recruited to the study – a low recruitment rate which may have been partly but probably not mainly due to the requirements imposed by the research.

The brief intervention protocol was followed by reductions in all drink-related measures six and 12 months later (consumption, AUDIT score, drink-related problems), while among those given usual advice, only consumption at 12 months fell, and then less than in the protocol group. However, none of the outcome differences between the two types of intervention were statistically significant. Across both groups there was little change in consumption at 12 months (reduced by just two UK units a week from a baseline average of 25) or drink-related problems, but there was a significant reduction in the average AUDIT score from about 11 to about 10. In the 12 months following the interventions, health care costs and these plus the intervention costs were on average over £100 lower for the protocol group (about a quarter less than for the usual advice group), but again, these differences were not statistically significant. The authors concluded that the trial provided "no evidence that nurse screening and brief intervention should be routinely provided", but also that it did not rule this out given the non-significant advantages of the brief intervention protocol.

An accompanying study (1 2) tested ways to support practices nurses in the implementation of a brief alcohol screening and intervention programme. Of 270 nurses approached, 212 agreed to use the programme for three months and 128 implemented it, screening 5541 patients and intervening with 1333. Training or training plus support encouraged far more nurses (54%) to use the package than just delivering it to them (30%); the upshot was that for each 'active' nurse, the training options cost less – about £120 compared to £155. Trained nurses also screened and intervened with many more patients.

The most expensive option (training plus continued support) resulted in the most interventions and was also the least costly per patient who received a brief intervention. Nevertheless, nurses offered this support typically screened just four patients a month and intervened with one every two months. The biggest shortfall was in the screening rate; just 2% of patients seen by the nurses were screened. Of the 28% found to be at risk, an intervention was delivered to 64%. With training but without support the corresponding figures were 1%, 24%, and 60%. The screening shortfall was partly because universal screening was not attempted. Instead most of the nurses who implemented the programme did so when they had time not just for screening but for any ensuing intervention, and in specific contexts such as new patient registrations, well person checks, or chronic disease clinics, when screening was a natural part of broader health checks. Nurses who felt able to enlist receptionists to give out screening questionnaires also implemented the programme more extensively.

The UK policy context

In recent years Britain has made progress in extending alcohol screening and brief intervention to more primary care patients, but it is unclear whether this has been to the degree needed to make noticeable public health gains, and provision remains patchy. Details below.

In both England and Scotland, the prime objective for primary care is to screen new patients and/or those thought in advance to possibly be at risk from their drinking. Screening newly registered patients was the reimbursement indicator for the enhanced alcohol service. Initially for two years from 2008 but then extended to March 2013, this requires all primary care trusts in England to offer GP practices in their areas the chance to contract to provide alcohol screening and brief intervention to their new patients. If they wish, local commissioners can go further to contract for more extended services. Also in England, directors of public health are expected to include such activity among attempts to address the population-wide determinants of ill health.

In line with Scotland's own practice recommendations, national policy in Scotland prioritises screening and brief intervention, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions supported by dedicated funding. The target was exceeded; over the three-year period 174,205 alcohol brief interventions were recorded across the three priority settings – primary care, accident and emergency departments, and antenatal services. In 2008, the Welsh Assembly Government announced its intention to instigate a programme to promote alcohol brief interventions in both primary and secondary health care settings.

These policy initiatives implement guidelines from Britain's National Institute for Health and Clinical Excellence (NICE), which encourage screening for new patients and in circumstances where both patient and doctor might feel it was 'natural' and justified to ask about a patient's drinking. Touching on a key barrier to widespread implementation beyond these circumstances, the guidelines cautioned that, "Clinical consultations for non-alcohol-related medical problems can be an inappropriate time to discuss alcohol use, given that users are focused on the condition for which they are seeking advice," and recognised the greater acceptability of discussing drinking "in a context that is related to the purpose of the visit (such as lifestyle assessment or chronic condition monitoring)".

It is unclear how far things have moved on since 2008 when a national audit found that systematic screening by GPs in England was the exception and few patients were screened or offered brief advice. The requirement to offer screening and intervention contracts to GPs has generated more activity, but far from consistently, and the quality and even the reality of the services supposed to have been provided has been questioned. In London in 2010 a survey of staff responsible for local alcohol policy indicated low levels of investment in developing the role of GPs in screening and treating alcohol use disorders. Nearly two thirds of areas had yet to invest in or develop screening systems beyond those nationally required. In one large London borough not known for the rarity of its drinking problems, over half the practices which had contracted to provide screening failed to identify any risky drinkers using the stipulated screening survey, and in a year screening resulted in just ten people being referred for treatment. Whilst reluctance to address drinking 'out of the blue' is understandable, there is even reluctance to raise the topic in general health and well-being assessments.

Last revised 16 October 2013. First uploaded 23 November 2011

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2013 Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial

STUDY 2012 Alcohol screening and brief intervention in emergency departments

STUDY 2014 The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

STUDY 2010 The impact of screening, brief intervention and referral for treatment in emergency department patients' alcohol use: a 3-, 6- and 12-month follow-up

STUDY 2011 An evaluation to assess the implementation of NHS delivered alcohol brief interventions: final report

STUDY 2013 Screening and brief intervention for alcohol and other drug use in primary care: associations between organizational climate and practice

STUDY 2010 Alcohol screening, brief intervention, and referral to treatment conducted by emergency nurses: an impact evaluation

REVIEW 2002 Investing in alcohol treatment: brief interventions

STUDY 2012 Alcohol screening and brief intervention in probation





12-month follow-up after brief interventions in primary care for family members affected by the substance misuse problem of a close relative.

Velleman R., Orford J., Templeton L. et al.
Addiction Research and Theory: 2011, 19(4), p. 362–374.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Velleman at r.d.b.velleman@bath.ac.uk. You could also try this alternative source.

In England a brief primary care counselling programme for family members living with a relative with substance use problems unusually aims primarily to improve the family's lives and coping rather than that of the substance user. Even a year later it seems to have succeeded, and the improvements accumulated rather than faded.

Summary A UK-originated brief counselling programme for family members living with a relative with substance use problems aims primarily to improve the family member's lives and coping rather than that of the substance user. 136 GP practices in the West Midlands and South West regions of England had been randomly allocated to two versions of the programme, which were delivered by 168 specially trained primary care staff. Initially the 143 family members recruited for the trial by the practices were followed up 12 weeks later. At that time interviews repeating baseline assessments found significant reductions in stress and improvements in coping skills, regardless of which version of the programme the practices had been allocated to. The featured report extended the follow-up to a year to test (among other things) whether improvements had been sustained and whether differences had later merged between the impacts of the two versions.

Known as the '5-Step Intervention', the programme guides the primary care clinician to listen (step 1) to the family member, provide information (step 2), help them look at their coping strategies (step 3) and sources of social support (step 4) and explore alternatives, and finally (step 5) to summarise the intervention, assess whether further work is needed, and if so, to refer on to an appropriate service. Normally undertaken in five sessions, the trial tested this implementation against a one-session version. In both the family member was given a self-help manual to aid them in sustaining the strategies introduced and developed during counselling.

Nearly 9 in 10 of the family members recruited for the trial were women. Over the past on average nearly nine years, few had sought help for themselves in relation to what was usually their live-in husband, partner or child, 60% of whom were seen as having a drink problem and the remainder drugs or drink and drugs. When recruited to the study, the family members were usually not attending the surgery for help with coping with their relative, but the need for this help emerged during the consultation or was known to the clinician.

For the 12-month follow-up, extensive efforts resulted in 63% of the family members returning by post a self-completion questionnaire booklet assessing among other things their coping and social support. On all the assessed variables including their initial degrees of distress they were comparable to full starting sample.

Main findings

As at the 12-week follow-up, there remained no significant differences between those offered the five-session and those offered the one-session programme in their ways of coping Such as engaged, tolerant-inactive and withdrawal coping. with their relatives' substance use, symptoms of stress or distress, and their ratings of the harmful impact of substance problems on the family. However, across both interventions there had been further significant improvements on all these dimensions. Of the 56% who said things were better Another 24% said they were the same and 20% worse. for them now than at the start of the study, nearly two thirds attributed at least some of this improvement to the intervention, but generally they did not see it as highly influential. Improvements were no less among family members who had suffered with their relatives' problems for many years as opposed to a shorter time.

Nearly half (47%) thought their relatives' substance use problems had not improved since the start of the study, yet even these family members had (to a lesser degree than others) experienced continuing significant improvements in their coping and symptoms of stress or distress. However, as opposed to at 12 weeks, by a year there was no longer a statistically significant reduction in their ratings of the degree to which their relatives' substance use problems were harming the family.

Stress and distress were greater and improvements less among parents rather than partners.

The authors' conclusions

Among this sub-sample who seemed representative of the full sample, a year later there remained no differential impact of the abbreviated versus the full programme, but essentially equivalent continued improvements in how well they coped with their relative's substance use problems and in their levels of stress and distress. Most still saw their situations as better than before the interventions, and most of these saw the interventions as partly responsible.

These and other findings from the UK and Italy suggest that this relatively simple and brief intervention enables family members to re-appraise their lives with respect to their substance misusing relative, to see the impact as less of a strain, to revise their ways of coping, and to experience a resulting reduction in stress and distress. Testing the intervention against no intervention would afford a securer indication of the degree to which the improvements were due to the programme or might have happened anyway, but for various reasons Primarily the fact that their situations had on average extended over nine years and yet the family members remained highly distressed before the interventions. it seems likely that the programme did lead to positive change for family members.

From the information gathered it seems unlikely that seeking further help (few did) or following the self-help manual (only a quarter consulted it between the 12-week and one-year follow-ups) provided by the study accounted for the continuing improvements. Instead it seems that the family members – even those with many years of attempting to cope behind them – were empowered themselves to re-appraise the impact their relatives were having on them and the ways they respond, setting in motion a series of appraisals and responses which continued long after the intervention without having to be reinforced by further professional involvement, and even if the relative's substance use problems continued unabated.

However, it is important not to overstate the impact of the intervention. Though there were enduring and accumulating improvements in both coping and stress/distress, the latter remained much higher than in the general population and only fell to levels found among psychiatric patients, while the degree to which the family members had to mount coping strategies remained high. It remains a challenge to develop this or other interventions so that affected family members can reduce their symptom and coping levels even further.

Another implication of the findings is that on the measures taken by the study, the one-session version of the programme is much more cost-effective the five-session version. As a result, an on-line implementation of the abbreviated version has been developed which family members can access directly. As of the beginning of December 2011 it is being re-worked following evaluation and is expected to become active again by mid-2012.


Findings logo commentary As with alcohol brief interventions in general in primary care, an earlier report from this study makes it clear that despite the offer of funding, it was difficult to find practices and workers willing to take on the family intervention. Among those who initially agreed, more dropped out after being allocated to the longer five-session version, contributing to the fact that almost twice as many family members (92 v. 51) received the shorter version. A previous study in England of the same intervention reported that just 5% of primary care workers took up the offer of being trained in the intervention and under 2% found suitable family members and actually delivered it, an uptake rate far short of the presumed need among their patients. This degree of selectivity of workers and patients raises doubts about whether more comprehensive adoption is possible, and whether if it happened, the results would be the same as in the trials.

For good reasons the authors of the study are convinced that the intervention itself triggered the changes which led to the improvements experienced by the family members. It is hard to believe that simply ignoring their plights would have made as much of a difference as exploring them and suggesting remedies. But the fact that one session of advice was equivalent to an intended five (in practice, typically four) raises the issue of whether a less sophisticated intervention might have worked just as well, such as the GP or nurse merely showing an interest in the family members' predicaments, and turning the consulting spotlight on their needs rather than those of the problem substance user. The very act of being (for baseline assessment purposes) systematically quizzed by the primary care clinician about their ways of coping with problems and the harmful impact of their relative's substance use on them and on the family may have provoked reflection on the need to minimise the damage and cope better. Certainly in studies of brief alcohol interventions focused on the drinker themself, control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. groups exposed to no intentional intervention have sometimes reduced their drinking as much as those exposed to the trialled intervention. In one randomised study of British university students, merely completing the AUDIT questionnaire often used to screen for risky drinking in brief intervention studies was associated with changes in the self-reported degree of hazardous drinking of the same order as when assessment has been followed by brief advice.

Whatever the resolution of that speculation, the study offers hope that paying attention – even briefly – to the problems and stress faced by family members sharing their lives with a problem alcohol or drug user can alleviate that stress, and can do so even if this distressing situation has been going on for many years. In other words, it seems worth primary care staff enquiring in to these issues and offering advice and support. At the very least, systematising that advice and support in to a specific programme should help give staff the confidence to take the first step of asking the questions, knowing they have something in their armoury to respond with if needed, and that those strategies have been associated with some remission in stress in the featured study and others. For more about the programme see this special issue of the journal Drugs: Education, Prevention and Policy devoted to the 5-Step Intervention.

Thanks for their comments on this entry in draft to Richard Velleman of the University of Bath and Jamie Pennycott of Southend's Drug and Alcohol Team in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 05 December 2011

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The effectiveness of anti-illicit-drug public-service announcements: a systematic review and meta-analysis.

Werb D., Mills E.J., DeBeck K. et al.
Journal of Epidemiology and Community Health: 2011, 65, p. 834–840.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Wood at uhri-ew@cfenet.ubc.ca.

Governments spend millions on them and they may serve political functions, but do anti-drug media campaigns prevent drug use? This first systematic review finds no strong evidence that they do and some that they can have the opposite effect.

Summary Nations including the UK, USA, Australia and Canada have mounted media campaigns featuring commercials aimed at preventing the use of illicit drugs, generally targeted at young people. Despite their popularity, what impact such campaigns have is unclear. The featured review aimed to fill this gap by analysing relevant English-language articles deriving from studies assessing impacts on intentions to use illicit drugs and/or actual self-reported use.

The review prioritised studies which randomised participants to be exposed or not to the adverts, but also included other studies, and went beyond studies published in peer-reviewed journals to consider conference abstracts and government reports. Eleven studies published between 1989 and 2008 were found. Four observed the impacts of national and local campaigns by surveying the intended audiences, while six recruited study participants and randomised them to view, listen or read campaign adverts or not. Another randomised trial exposed participants to different kinds of campaign ads. All the randomised studies were from the USA and involved young people no more than 22 years of age, and all but one assessed the young people's immediate reactions to the ads. All but one of the observational studies was also from the USA.

Main findings

Two of the randomised studies found the ads had some of the intended effects, in one case slightly weakening intentions to use illicit drugs, in the other, slightly bolstering intentions to call a drug abuse hotline. Another five found the ads had no significant impacts, or impacts the reverse of what was intended. Data required to pool findings on intentions to use illicit drugs was available for six comparisons deriving from randomised trials. These amalgamated to a small impact amounting to an effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. of 0.15 in the 'wrong' direction – strengthening intentions to use. However, by conventional criteria this result was not statistically significant, so could have reflected chance variation rather than a true impact of the ads.

A similar amalgamation of results from observational studies found that campaigns were associated with a very small reduction in the use of illicit drugs amounting to an effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. of 0.04. Though statistically significant, the comparisons which contributed to this figure registered very variable outcomes from increased to decreased use. Notably, the two national studies of national campaigns in Australia and the USA detected no significant impacts on illicit drug use. In Australia, young people did become more negative about the effects of amphetamine and ecstasy, but in the USA they became more accepting of cannabis use.

The authors' conclusions

This review concludes that there is insufficient data to support the conclusion that anti-illicit drug public service announcements affect intention to use illicit drugs or self-reported use among targeted youth, and suggests that campaigns can have negative as well as positive effects. Taken together, randomised studies offer no support for a preventive impact of the adverts used in anti-drug campaigns and no study has investigated long-term impacts, while survey studies observing the effects of campaigns in the real world are equivocal.

It could be that the theories underlying the research, which are predicated on a direct relationship between intention and behaviour, fail to account for socio-demographic, environmental and other variables which affect an individual's ability to act according to their intentions. In particular, most evaluations do not take account of features such as ethnicity, where people live, their incomes, and housing situations. One study also found that secondary school children who saw anti-cannabis ads, and then were randomly allocated to an on-line 'chat' about the ads, subsequently recorded attitudes and beliefs significantly less favourable in prevention terms than their peers not allocated to the chats, suggesting that social interaction can affect a campaign's impacts.

The ability to draw any firm conclusions is however limited by the paucity of studies especially of long-term impacts, and by the variability and quality of the available studies.


Findings logo commentary The conclusion that anti-drug campaigns cannot be shown to generally have achieved their objectives rests on the assumption that their sole objectives are drug use prevention. But as the authors of the featured review hint, such campaigns perform multiple tasks, including perhaps bolstering support for uncompromising anti-drug laws and policies. The most notable failure in prevention terms was the US National Youth Anti-Drug Media Campaign illustrations. However, according to a watchdog on US government spending, its real objective was to persuade US states not to allow cannabis to be legally supplied for medical purposes. The degree to which it may or may not have succeeded in this objective has never been formally evaluated.

Pothead poster featuring "My Anti-Drug" campaign strapline

Taking the campaigns at face value, the greatest concern is the potential for counterproductive impacts. There is evidence that these can be generated in several ways and by adverts which seem to carry the strongest anti-drug messages. These may imply that drug use is very common and hard to resist, provoke a 'don't tell me what to do' counter-tendency to use drugs, be rejected as contrary to personal experience, or generate discussions among young people dominated by those most more vociferously pro-drug. Examples below.

Pot Quiz postcard

Evaluators suspect that the explicitly anti-drug messages of the US National Youth Anti-Drug Media Campaign initiated in 1999 were countered by an "implicit message – that drugs are a big problem and their use is widespread ... and that resistance [to using them] may be difficult”. There was also the possibility that while most young people were unaffected by the ads, some resented being 'told what to do' and reacted by moving in the opposite direction. Such tendencies could have accounted for findings that social norms were more favourable to cannabis the more ads a child recalled experiencing, and a non-significant tendency for more exposure to be followed by a greater chance that the child expected to try cannabis during the following year.

As described by Findings, in one of the randomised trials included in the featured review, school children allocated to watch hard-hitting anti-cannabis ads featuring the 'gateway' scenario of cannabis use leading to 'hard drug' addiction ended up feeling more positive about cannabis and more likely to say they would use the drug than peers who had not seen the ads. The researchers conjectured that these children rejected the gateway depiction because it was contradicted by their own experiences, a speculation strengthened by the fact that these youngsters were indeed the ones most sceptical about cannabis leading to harder drugs.

Another study of 12–18-year-olds recruited in shopping centres found they reacted relatively badly to ads which showed cannabis being smoked. Youngsters unlikely in any event to use the drug reacted well to anti-cannabis ads regardless, but those the ads most needed to deter – the ones most likely to use the drug – saw the ads overall as less effective, and especially those which featured the drug or its use.

The featured review highlighted a study of secondary school children who saw anti-cannabis ads, and then were randomly allocated to engage or not engage in an on-line 'chat' about the ads. Compared to those who did not, youngsters who chatted following exposure to the ads subsequently recorded more pro-cannabis and less anti-cannabis beliefs or attitudes, more peer pressure to use cannabis, and less disapproval of cannabis use by adult authority figures. One mechanism seemed to be that young people most likely to use cannabis (those who value new, exciting and possibly risky experiences and have been most exposed to cannabis use) contributed most to the on-line chats and their comments tended to be relatively favourable to cannabis, generating a social climate more supportive of cannabis use. If such discussions are stimulated by anti-drug campaigns, these too could, the analysts speculated, have counterproductive impacts, especially among young people most likely to try drugs.

Thanks for their comments on this entry in draft to Dan Werb of the BC Centre for Excellence in HIV/AIDS, British Vancouver, Canada. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 25 November 2011

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2008 Effects of the National Youth Anti-Drug Media Campaign on youths

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