EFFECTIVENESS BANK BULLETIN 8 December 2008
EFFECTIVENESS BANK BULLETIN 8 December 2008
The entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, 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 Request reprint to send or adapt the pre-prepared e-mail message. The Summary is intended to convey the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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Reducing alcohol harm: health services in England ...
Measuring performance of brief alcohol counselling in medical settings ...
Screening, brief intervention and referral to treatment for drug and alcohol use ...
Network support for drinking and client-treatment matching ...
Primary care alcohol intervention: ranking health impact and cost effectiveness ...
Reducing alcohol harm: health services in England for alcohol misuse.National Audit Office.
The Stationery Office, 2008.
Official audit of work by the Department of Health and NHS to address the health effects of alcohol misuse. Describes a system whose infrastructure is clearly inadequate compared to the size of the task, but one recently taking steps in the right direction.
Summary Alcohol-related ill-health is an increasing burden for the National Health Service. Alcohol misuse costs the health service in the order of £2.7 billion a year, but efforts to address it locally are not in general well-planned. The Department of Health is however raising the profile of alcohol misuse by providing information and guidance to underpin local action, centred on encouraging primary care trusts (PCTs) to gauge their performance against the rate of alcohol-related hospital admissions. Hospital admissions for the three main alcohol-specific conditions (alcohol-related liver disease, mental health disorders linked to alcohol, and acute intoxication) have doubled in the last 11 years. There were also twice as many deaths from alcohol-related causes in the UK in 2006 as there were 15 years before, increasing from 4,100 to 8,800. Primary care trusts are responsible for setting local health priorities. But around a quarter surveyed by the NAO have not fully assessed alcohol problems in their areas. Many PCTs do not have a clear picture of their spending on services to address alcohol misuse and its effects on health. PCTs have often looked to their local drug and alcohol action teams to take the lead, but these bodies focus primarily on specialist services for dependent users of illegal drugs and alcohol. There is scope for the Department of Health to provide greater leadership to PCTs on alcohol misuse and the report recommends a number of specific measures to that end, such as guidance to help PCTs assess causes and to forecast trends in the level of alcohol harm in their localities. There is evidence that preventive services, such as brief advice by GPs and health workers, can reduce alcohol consumption and help to prevent longer term damage to health and there are some good local examples. From September 2008 the Department has provided an additional £8 million in support for such services. For people who have developed severe alcohol problems, there are considerable variations between different localities in access to specialist treatment services, and scope for better integration of hospital treatment with follow-on services such as psychiatry. The Department of Health has recently undertaken a series of new publicity campaigns to encourage sensible drinking. Research has shown that consumers tend to underestimate the amount of alcohol their drinks contain and are not clear about what is meant by a 'unit' of alcohol. Department of Health funding for such work was tripled to £6 million in 2008-09.
This report evaluates work by England's Department of Health and National Health Service to address the health effects of alcohol misuse from prevention to specialist treatment. It describes a system whose organisational and funding infrastructure is clearly inadequate compared to the size of the task, but one recently taking steps in the right direction. How far it has to go is indicated by the discrepancy between the treatment spend per dependent drinker as opposed to dependent drug user - £197 v. £1744. One of the major steps forward is to include alcohol-related hospital admissions among the national indicators by which health trusts and local partnerships are held to account, but signing up to this is optional (two-thirds of trusts and about half of partnerships have adopted it) and there are no direct consequences on the authorities if they fail to do so or perform poorly.
Last revised 01 December 2008
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Alcohol-use disorders: Preventing the development of hazardous and harmful drinking REVIEW 2010
Alcohol dependence and harmful alcohol use quality standard DOCUMENT 2011
Family doctors' alcohol advice plus follow up cuts long-term medical and social costs STUDY 2003
Drug and alcohol services in Scotland STUDY 2009
Alcohol screening and brief intervention in emergency departments STUDY 2012
Reducing the impact of alcohol-related harm to Londoners – how well are we doing? STUDY 2011
The government's alcohol strategy DOCUMENT 2012
Measuring performance of brief alcohol counseling in medical settings: a review of the options and lessons from the Veterans Affairs (VA) health care system.Bradley K.A., Williams E.C., Achtmeyer C.E., et al.
Substance Abuse: 2007, 28(4), p. 133-149.
Request reprint using your default e-mail program or write to Dr Bradley at willi@u.washington.edu
Having mandated universal screening for alcohol problems, the US health system for ex military personnel here thoughtfully addresses how to measure the degree to which this led to appropriate implementation of brief interventions.
Summary Brief alcohol counselling is a top US prevention priority but has not been widely implemented. The lack of an easy performance measure for brief alcohol counselling is one important barrier to implementation. The purpose of this report is to outline important issues related to measuring performance of brief alcohol counselling in health care settings. We review the strengths and limitations of several options for measuring performance of brief alcohol counselling and describe three measures of brief alcohol counselling tested in the Veterans Affairs (VA) Health Care System. We conclude that administrative data are not well-suited to measuring performance of brief alcohol counselling. Patient surveys appear to offer the optimal approach currently available for comparing performance of brief alcohol counselling across health care systems, while more options are available for measuring performance within health care systems. Further research is needed in this important area of quality improvement.
Having mandated virtually universal screening for alcohol problems, the US health system for ex military personnel faced the problem of how to measure its success in a way which could drive up the implementation of brief interventions in appropriate cases. It concluded that just four or five extra questions in patient satisfaction surveys could be used to assess how many should have been counselled and then how many actually were by being given feedback on their health risk and explicit advice to cut back. The study also demonstrates how an automated clinical reminder system for positive-screen patients can raise counselling rates to nearly 70%.
Last revised 29 November 2008
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Alcohol dependence and harmful alcohol use quality standard DOCUMENT 2011
Reducing alcohol harm: health services in England for alcohol misuse STUDY 2008
Alcohol-use disorders: Preventing the development of hazardous and harmful drinking REVIEW 2010
Reducing the impact of alcohol-related harm to Londoners – how well are we doing? STUDY 2011
Primary care intervention to reduce alcohol misuse: ranking its health impact and cost effectiveness STUDY 2008
Screening and brief interventions (SBI) for unhealthy alcohol use: a step-by-step implementation guide for trauma centers DOCUMENT 2009
Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later.Madras B.K., Compton W.M., Deepa A. et al.
Drug and Alcohol Dependence: 2008, in press.
Request reprint using your default e-mail program or write to Dr Madras at bertha_madras@hms.harvard.edu
This huge US study set out to test whether widespread screening and brief intervention for illegal drug use (not just heavy drinking) could be implemented in a variety of general medical settings and whether it was effective. Both tests seem to have been passed, but with some important caveats.
Summary Alcohol screening and brief interventions in medical settings can significantly reduce alcohol use. Corresponding data for illicit drug use is sparse. A federally funded screening, brief interventions, referral to treatment (SBIRT) service program, the largest of its kind to date, was initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) in a wide variety of medical settings. The study compared illicit drug use at intake and 6 months after drug screening and interventions were administered. SBIRT services were implemented in a range of medical settings across six states. A diverse patient population (Alaska Natives, American Indians, African-Americans, Caucasians, Hispanics), was screened and offered score-based progressive levels of intervention (brief intervention, brief treatment, referral to specialised treatment). In this secondary analysis of the SBIRT service programme, drug use data was compared at intake and at a 6-month follow-up, in a sample of a randomly selected population (10%) who screened positive at baseline. Of 459,599 patients screened, 22.7% screened positive for a spectrum of use (risky/problematic, abuse/addiction). The majority were recommended for a brief intervention (15.9%), with a smaller percentage recommended for brief treatment (3.2%) or referral to specialised treatment (3.7%). Among those reporting baseline illicit drug use, rates of drug use at 6-month follow-up (4 of 6 sites), were 67.7% lower (p < 0.001) and heavy alcohol use was 38.6% lower (p < 0.001), with comparable findings across sites, gender, race/ethnic, age subgroups. Among persons recommended for brief treatment or referral to specialised treatment, self-reported improvements in general health (p < 0.001), mental health (p < 0.001), employment (p < 0.001), housing status (p < 0.001), and criminal behaviour (p < 0.001) were found. The authors concluded that SBIRT was feasible to implement and that self-reported patient status at 6 months indicated significant improvements over baseline for illicit drug use and heavy alcohol use, with functional domains improved, across a range of health care settings and a range of patients.
As Findings readers have commented, brief advice is established for risky drinking but not so for the users of illicit drugs. Even rarer is brief advice triggered by screening tests among patients not specifically seeking this kind of help. The US
SBIRT study set about filling this gap by trialing practically universal screening for recent illegal drug use as well as heavy drinking at a variety of hospital, primary care and community health centres. The plan (implemented in nearly two-thirds of cases) was that positive screen patients would be given brief advice or, for the more severely affected minority, a short course of therapy or referral for specialist treatment. Key outcome measure was how many patients who had recently drank heavily or illegally used drugs were still doing so six months later. As the abstract documents, the answer was,
far fewer.
The proportion drinking heavily was cut by more than half and using cannabis by almost two thirds. Usage of less common drugs including heroin, cocaine and methamphetamine had been reduced by similar or greater amounts. Among the more severe cases, there were accompanying gains in quality of life and social functioning.
The two broad aims were to test whether such widespread intervention was feasible and secondly whether it was effective. Both tests seem to have been passed, but with some important qualifications. The study showed that intervention can be made to reliably follow on a positive screen; what we don't know is how many patients were
not screened,
Screening rates can be very low unless mandated, supervised and systematically encouraged.
though it is
believed
All adult patients within a particular healthcare setting were approached for screening and were asked whether they were willing to respond to a few questions about substance use; according to informal survey, the majority agreed, but this proportion was not quantified. Personal communication from Professor Madras, 4 December, 2008.
that most were. It seems likely that the six sites which applied for and were selected for the study were particularly keen on and/or ready to implement these initiatives. Elsewhere things might not go so well, especially if providers are required to fund and
staff
Screening and brief intervention were conducted by personnel specifically hired for these purposes.
the work themselves. The biggest question mark over effectiveness is the absence of a control group either not screened, or screened but not offered further help. Substance use can fall substantially simply as a result of being screened, assessed, identified as having a problem, subject to research procedures, or as over time problems resolve. A multi-national WHO study trialing screening and brief intervention for illegal drug use did feature a control group subject to screening and research procedures only. They reduced substance use significantly; though also statistically significant, extra reductions generated by the intervention were minor and not apparent at the US sites, where consent procedures were most extensive.
Last revised 03 December 2008
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Alcohol screening and brief intervention in emergency departments STUDY 2012
Injury rate cut in heavy drinking accident and emergency patients STUDY 2003
Brief alcohol interventions: can they deliver population-wide health gains? HOT TOPIC 2010
Network support for drinking: an application of multiple groups growth mixture modeling to examine client-treatment matching.Wu J., Witkiewitz K.
Journal of Studies on Alcohol and Drugs: 2008, 69(1), p. 21–29.
Reanalysis of the huge US Project MATCH alcohol treatment trial confirms that patients with pro-drinking social circles gained greater remission in drink problems when 'matched' to a therapy focused on generating a social circle (in the form of AA) with the opposite characteristics.
Summary The current study re-examined the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) hypothesis that individuals with high network support for drinking would have the best treatment outcomes if they were assigned to twelve-step facilitation (TSF). Drinking consequences, as measured by the Drinking Inventory of Consequences, was the primary outcome measure. Growth mixture models with multiple groups were used to estimate the drinking consequence trajectories of 952 outpatients during the 12 months following treatment for each of the three Project MATCH treatment conditions. Growth factors within latent trajectory classes were regressed on network support for drinking to assess whether treatment condition moderated the relationship between network support for drinking and drinking consequences over time. Three latent classes were identified, representing low (n = 154, 16.2%), medium (n = 400, 42%), and high (n = 398, 41.8%) levels of drinking consequences. Classes did not differ across treatment groups. Greater network support for drinking predicted more drinking consequences over time but only for clients assigned to cognitive-behavioural therapy and motivational enhancement therapy, not TSF. This study provides further support for one of the original Project MATCH matching hypotheses: clients with social networks supportive of drinking had better outcomes immediately after treatment if they were assigned to TSF. Because the original Project MATCH studies found this matching effect only at the 3-year follow-up, these results add validity to the network support for drinking matching effect. The study also provides additional evidence that accounting for heterogeneity in alcohol treatment outcomes is important for accurately estimating treatment effectiveness.
The huge US Project MATCH study of psychosocial therapies for
dependent
A few of the problem drinkers in the trial were not assessed as dependent.
drinkers discovered that
patients
But only those in the arm of the trial where they were newly (re)entering treatment, not where the therapies were effectively aftercare following immediately on a period of intensive treatment such as inpatient detoxification.
whose close social circles were laden with drinkers and people supportive of drinking drank less when therapy focused on engagement with 12-step groups (typically AA) than after therapies without this focus. It made sense: this option rebalanced their network towards people who were at least trying not to drink and supported abstinence. Curiously, this effect emerged three years after therapy, but not in the first year, and the analysis did not test if it extended to drink-related psychological and social problems as well as drinking itself. The current analysis aimed to tie up these loose ends. Its innovation was to segregate patients in to three groups based on patterns in the remission of
drinking problems.
At some of the follow-up points up to 47% of patients did not complete the drinking problems/consequences questionnaire. Despite catering for this in the analysis, this much missing data weakens confidence in the findings.
About 1 in 6 started with relatively few problems which rapidly subsided to a sustained low level. The rest divided evenly in to patients with severe problems which gradually remitted, and those whose moderately severe problems improved during therapy, then stayed about the same. Depending on their social networks, these patients responded differently to the therapies. As expected, after the two non-12-step therapies, patients with pro-drinking networks experienced worsening drink-related problems. The 12-step option countered this influence; as with drinking itself, patients improved just as well in terms of drink-related problems regardless of whether they started treatment with a pro- or anti-drinking social circle. Bottom line: when a patient's closest friends/family drink and support drinking, help them recruit a social circle with the opposite characteristics. When they already have this, it's best to focus instead on the reasons (such as motivational or skills deficits) why they nevertheless drink excessively.
Last revised 02 December 2008
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Brief motivational therapy minimises health care costs except among more problematic drinkers STUDY 2001
Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes STUDY 2010
Still hard to find reasons for matching patients to therapies STUDY 2008
Style not content key to matching patients to therapeutic approaches STUDY 2008
Therapist directiveness is an important influence on outcomes STUDY 2005
Adjust therapist directiveness to client resistance STUDY 2006
Patient reactance as a moderator of the effect of therapist structure on posttreatment alcohol use STUDY 2009
Soup kitchen turned into therapeutic setting STUDY 2006
Primary care intervention to reduce alcohol misuse: ranking its health impact and cost effectiveness.Solberg L.I., Maciosek M.V., Edwards N.M.
American Journal of Preventive Medicine: 2008, 34(2), p. 143–152.
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In this comprehensive analysis, screening for risky drinking and brief advice was estimated to be among the most cost-effective preventive services GPs could offer, ranking alongside common interventions such as screening for high blood pressure or immunisation against influenza.
Summary The US Preventive Services Task Force has recommended screening and behavioural counselling interventions in primary care to reduce alcohol misuse. This study was designed to develop a standardised rating for the clinically preventable burden and cost-effectiveness of complying with that recommendation that would allow comparisons across many recommended services. A systematic review of the literature from 1992 through 2004 to identify relevant randomised controlled trials and cost-effectiveness studies was completed in 2005. Clinically preventable burden (CPB) was calculated as the product of effectiveness times the alcohol-attributable fraction of both mortality and morbidity (measured in quality-adjusted life years or QALYs), for all relevant conditions. Cost effectiveness from both the societal perspective and the health-system perspective was estimated. These analyses were completed in 2006. The calculated CPB was 176,000 QALYs saved over the lifetime of a birth cohort of 4,000,000, with a range in sensitivity analysis from -43% to +94% (primarily due to variation in estimates of effectiveness). Screening and brief counselling was cost-saving from the societal perspective and had a cost-effectiveness ratio of $1755/QALY saved from the health-system perspective. Sensitivity analysis indicates that from both perspectives the service is very cost effective and may be cost saving. Conclusions: These results make alcohol screening and counselling one of the highest-ranking preventive services among the 25 effective services evaluated using standardised methods. Since current levels of delivery are the lowest of comparably ranked services, this service deserves special attention by clinicians and care delivery systems.
The aim was to help US primary care practices prioritise preventive interventions to gain the greatest extension in healthy life span across their patient caseload. Screening for risky drinking and offering brief advice was judged among the most cost-effective, ranking alongside widespread interventions such as screening for high blood pressure or immunisation against influenza. Calculations were based on alcohol interventions which could be implemented across the at-risk population of a busy practice, typically taking 10 minutes repeated annually up to age 54. Studies suggested that as a result, more than one in six extra problem drinkers would be in remission. Taking all costs and savings in to account (ie, not just those related to health or health services), society would save an estimated $254 per person offered screening.
Despite its high ranking, the authors noted that alcohol screening and advice are much less widely implemented than similarly cost-effective interventions. It follows that the greatest scope for improving health lies in extending their coverage. However, there are reasons why alcohol screening is relatively infrequent – notably, GPs' reluctance to 'artificially' introduce drinking in to consultations about other complaints. Given this, the big question mark is over whether substantial extension is realistic. Also, gains varied widely when the authors varied assumptions about the impact of counselling on drink-related problems. Such variation has been noted in studies, suggesting that the anticipated health gains can't be guaranteed in any particular context.
Last revised 01 December 2008
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Alcohol-use disorders: Preventing the development of hazardous and harmful drinking REVIEW 2010
Reducing alcohol harm: health services in England for alcohol misuse STUDY 2008
Alcohol screening and brief intervention in emergency departments STUDY 2012
Alcohol screening and brief intervention in primary health care STUDY 2012
Reducing the impact of alcohol-related harm to Londoners – how well are we doing? STUDY 2011
Family doctors' alcohol advice plus follow up cuts long-term medical and social costs STUDY 2003
A&E units save health service resources by addressing drinking STUDY 2006
