Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 23 May 2012

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

Crucial British alcohol screening and brief intervention studies

For the future of alcohol screening and brief intervention in Britain, studies do not get more important than those highlighted in the first three entries in this bulletin. Awaited by government before extending the national primary care framework, this suite of three studies under the SIPS umbrella delivered remarkably consistent findings. Whatever the setting – primary care, emergency departments or probation – a year later the proportion of risky drinkers had fallen by 16–17%. And whatever the intervention, it made no substantial difference; an alcohol advice booklet plus a sentence or two warning the patient about their risky drinking was not improved on by adding extended and individualised counselling. Do just the minimum, is the message austerity-hit commissioners might take from the studies, but that would be to over-read their implications. Based on factsheets and conference presentations, this preliminary take on the findings will be updated as the academic analyses emerge. In this bulletin we also take the opportunity to draw attention to a relevant US guide.

More QALYs to the pound from brief warning in primary care ...

Emergency departments need specialist support ...

From offenders on probation, hints of the value of extended advice ...

US guide to emergency unit alcohol screening and brief advice ...


Alcohol screening and brief intervention in primary health care.

McGovern R., Kaner E., Deluca P. et al.
Institute of Psychiatry, King's College London, 2012.
Unable to obtain a copy by clicking title? Try this alternative source.

The primary health arm of the largest alcohol screening and brief intervention study yet conducted in Britain found that the proportion of risky drinkers fell just as much after the most minimal of screening and intervention methods as after more sophisticated and longer (but still brief) alternatives.

Summary This account has been superseded by an account based primarily on a later formally published report. It is retained here for archival purposes only. Please go to this analysis for the latest report.

The SIPS project

This account is based on preliminary findings released by the SIPS project in the form of factsheets and conference presentations rather than peer-reviewed publication in academic journals. Later more detailed and scientifically formal accounts of these and other findings (such as what was actually done by the interventionists and what patients thought of it) will be incorporated as they emerge, and mailing list subscribers will be alerted to any alterations in the findings or their implications. Some of the documents to which links are provided may no longer be available on the SIPS project web site.

The project was funded by the UK Department of Health in 2006 to evaluate the effectiveness and cost effectiveness of different ways of identifying risky drinkers through routine screening, and different forms of brief advice to help them cut back. Other aims were to assess the feasibility of implementing such procedures in typical practice settings, and to discover what made these more or less likely to succeed.

Conducted in three English regions (London, the South East, and the North East), the project took the form of three randomised controlled trials in different types of settings: nine emergency departments; 29 GP surgeries; and 20 probation offices. After summarising common features across the three trials, this account focuses on the emergency department study, relying largely on a factsheet produced before formal publication of the findings.

All three trials involved random allocation of practices, departments or offender managers to different variants of screening and intervention. Staff seeing adult patients or offenders for usual purposes in these settings asked them to consent to screening and basic data collection. Those who screened positive were further asked to join the study of the interventions, usually The exception was the most intensive of the interventions in emergency departments and probation offices, intended to be reserved for specialist alcohol workers. to be delivered by the same staff after training by the study. To assess changes in their drinking and related issues, patients and offenders who were eligible for Across all three trials patients or clients already in treatment for drink problems were excluded as were those severely injured, suffering with a serious mental health problem, or who were grossly intoxicated or homeless. and agreed to participate in the intervention study were followed up six and 12 months later.

Screening methods

Three quick ways to identify risky drinkers were tested for feasibility and accuracy, the latter defined by how well they duplicated corresponding results from the AUDIT screening questionnaire, widely used to determine whether someone is probably drinking at hazardous, Scoring at least 8, the cut-off used by the study. harmful or possibly dependent levels.

Single question: The simplest and quickest method was to ask, "How often do you have eight (or for women, six) or more standard drinks Each drink is roughly a UK unit of 8gm alcohol. on one occasion?" Monthly or more was considered a positive screen, meaning the respondent would be offered a brief intervention to help them cut back.
FAST Alcohol Screening Test: As used in the study, this begins with the question above and registers a positive screen if the response is weekly or more often. Otherwise three further questions About how often in the last six months the respondent has been unable to remember what happened during the previous night's drinking, failed due to drink to do what was normally expected of them, or experienced concern over their drinking from a relative, friend, or health professional. are asked. Scores in response to the four questions are summed So that, for example, people who have (even if in all cases less than monthly) drunk excessively, and forgotten what happened and failed to meet obligations would screen positive, as would someone who said they had never drunk excessively yet had either forgotten or failed to meet obligations at least weekly, or experienced concern on more than one occasion. to determine whether to proceed with intervention.
Paddington Alcohol Test (PAT): Used only in the emergency department study.

Interventions and assessing their impacts

Patients identified as risky drinkers by these methods were all offered advice of some kind, so the study could not assess the absolute impact of this advice, only how the impacts of one variant differed from those of another. The main yardsticks These figures were adjusted for any significant differences between the patients on characteristics the study found related to how likely they were to end up drinking safely. were the proportions of patients who six and 12 months later did not score as hazardous (or worse) drinkers on the AUDIT questionnaire, which assesses alcohol intake and other indicators of harmful or dependent drinking. Other assessments included drink-related problems, quality of life, and use of services. Crime and health service costs before the study and over the 12-month follow-up were used to assess cost effectiveness in terms of gains in quality-adjusted years of life per £ change in costs to society.

All the patients and offenders in the intervention trial were given a standard The UK Department of Health's How much is too much? booklet, was the standard official public information available at the beginning the SIPS project. alcohol information and advice booklet, supplemented by a sticker with contact information for local alcohol treatment services. At issue was whether also offering different types and degrees of advice would make a difference to later drinking.

Brief feedback: At its most basic, the booklet was accompanied only by very brief feedback from the health care or criminal justice practitioner who did the screening that the screening test had indicated the patient or offender was drinking "above safe levels, which may be harmful to you".
Brief advice: The next level supplemented booklet and feedback with five minutes of advice closely related to the content of the booklet. This was based on a leaflet which the worker left with the drinker after working through it with them according to a standard protocol, including comparison with population drinking levels. Though not always the case, ideally this would be seamlessly delivered by the person who did the screening and handed over the booklet.
Brief lifestyle counselling: The most intensive (but still brief) of the interventions added what was intended to be about 20 minutes of lifestyle counselling to the brief advice described above. This too was based on a leaflet, but practitioners could adapt the intervention to the needs of the drinkers and their willingness to think about further controlling their drinking. Staff were trained to use techniques from motivational interviewing and health behaviour change counselling to lead the drinker to consider the pros and cons of their drinking and their readiness to cut down, before if appropriate formulating a plan for doing so and overcoming possible obstacles. This counselling was done at an appointment In emergency and probation settings, appointments with specialist alcohol workers recruited for the studies. made after the brief advice phase of the intervention.

The primary care study

This account also draws on a description of the study's methodology and a conference presentation of the findings. In the UK, hazardous and harmful drinkers outnumber dependent drinkers 7:1. The greatest population-wide impact on alcohol-related problems can be made by identifying and intervening with these drinkers, even before they are aware of any problems or seek help. Primary care is an ideal setting, as this is generally the first point of contact with health services, one in five patients drink at hazardous or harmful levels, and studies have found brief interventions there reduce drinking by 4–5 standard drinks per week.

However, questions remain about the best screening strategy, whether longer or more sophisticated interventions work better, impacts in normal practice, and cost effectiveness, all questions addressed by the overall design of the SIPs trial. Additional to these common features, the primary care study tested its two screening methods (the single question and the FAST Alcohol Screening Test) in both a 'universal' form, which involved asking all eligible adult patients about their drinking, and in a 'targeted' form, which posed these screening questions only to those newly registering with the practice or whose complaints High blood pressure, mental health problems, gastrointestinal problems, or injuries. suggested excessive drinking – a strategy which might make screening more acceptable Partly because the questions can flow naturally from the main reason for the patient's attendance. to both staff and patients, and therefore more widely implemented. Also, the most extended intervention was to be delivered by specially trained practice staff rather than (as in emergency and probation studies) by specialist alcohol workers recruited for the trial.

In each of two areas (the North East; London and the South East) the aim was to recruit 12 GP practices Selected to have no existing programme of alcohol screening and brief intervention. to the study, and to randomise them in such as way that within each region, one practice was allocated to each of the possible 12 combinations of the two screening strategies, two screening methods, and three brief interventions. In the event, 29 practices were recruited. They were to be financially compensated for the time they would spend on research procedures and for each patient screened and advised or counselled about their drinking, with a greater payment for the more extended counselling option. Payments were intended to reflect those which might be applied if alcohol screening and brief intervention were among the national quality criteria agreed for general practice.

Main findings

Despite staff enthusiasm, barriers to implementation cited by staff included workload pressures, lack of time, confidence or knowledge, concerns about patients' attitudes to being asked about drinking, and lack of follow-up services. Nevertheless, of the 29 practices, 17 managed to implement the trial as intended using only their own staff for recruiting patients to the study and for screening and intervention. At the other 12, researchers and the specialist alcohol workers who had trained the staff had to help out. Implementation was more successful where there were supportive managers and the research staff were able to engage with and provide ongoing support to individual staff.

In the end, over 15 months, 3562 patients were screened, of whom 2991 were eligible to participate in the study. Of these, 900 (3 in 10) screened positive and 756 agreed to join the intervention study. Typically white men, they averaged 44 years of age and an AUDIT score of 12–13, a medium severity Scores 8–15 inclusive. Higher scores represent a high level of alcohol problems; lower, non-hazardous drinking. of drinking problems, though around a quarter scored in the more severe range. Around 80% were followed up six and 12 months later.

Targeting screening meant fewer patients had to be screened in order to identify a given number who screened positive. Of the two screening tests, in terms of identifying people who screened positive for risky drinking on the AUDIT, the FAST Alcohol Screening Test was preferable (89% were identified) to the single question (81%), and significantly so at identifying people whose AUDIT scores indicated a medium severity of alcohol problems, the range thought appropriate for brief interventions.

Positive screen patients were then allocated to different forms of intervention. Virtually all allocated to brief feedback or advice received this plus the alcohol advice booklet, the full intended interventions. This was not the case for those allocated to lifestyle counselling; though nearly all received the five-minute brief advice and booklet delivered immediately after screening, only 57% attended a later appointment for more extended counselling.

Six and 12 months later the proportions of patients scoring as at least hazardous drinkers on the AUDIT questionnaire (initially around 80%) had fallen overall by 11% and nearly 17% respectively, but neither on this measure nor on all the other major yardsticks of patient drinking and welfare (average AUDIT scores, alcohol-related problems and health-related quality of life) had there been significantly greater changes after one type of intervention than another. The expected extra impacts of more extensive advice and counselling had not materialised; at 12 months the reductions were 17% after the two briefest options and only slightly more – 20% – among patients allocated to counselling. Neither The prior screening method through which the patient had been identified also made no difference to their later drinking. could it be shown that one intervention was better than another for particularly heavy drinkers.

On one measure there was however a statistically significant extra improvement among patients allocated to counselling – the proportions who said they were at least trying to cut their drinking. Among brief feedback patients this barely changed over the course of the study, hovering around 30%, but among counselling patients it increased from 28% at baseline to 46% and then 48% six and 12 months later. Looking back 12 months later, counselling patients too were on average slightly but significantly more appreciative of the quality of the communication and the general manner of the interventions they had experienced.

Another difference was in costs, averaging £2.40 per patient for the brief feedback option, £18.71 for brief advice, and £71.00 for lifestyle counselling. These costs were however overshadowed by the costs of the patients' health service use and crime over the 12 months of the follow-up. These totalled £3040 for brief advice patients, due to high crime costs, several hundred pounds more than for the other two groups. Contrary to expectations, the least intensive option – brief feedback – resulted in the greatest gains in quality-adjusted life years. Valuing each of these years at £20,000, it meant there was a 62% probability that this was more cost effective than brief advice and 87% in relation to more extensive counselling.

The authors' conclusions

Given financial incentives, training and ongoing specialist support, most typical primary health care practices can implement alcohol screening and brief intervention. Most difficult to implement was the lifestyle counselling intervention, which required appointments to be made and kept, rather than the seamless delivery of briefer interventions during the patient's initial attendance.

In terms of screening, the Fast Alcohol Screening Test option proved best at identifying risky drinkers.

When it came to how to respond to these risky drinkers, the more intensive interventions offered no significant clinical benefits, even for heavier drinkers. On average all were followed by reductions in the severity of drinking, results which may have been due to the interventions, but may instead have been due to natural changes in relatively extreme behaviour, or to the impact of being repeatedly assessed for drinking and recruited to a trial of drinking interventions.


Findings logo commentary See these Findings analyses for the sister studies conducted in emergency departments and probation offices. The following commentary explores common themes across these settings and any differences, and supplements these with comments focused on the featured setting, primary care. The general picture was that implementation often required specialist support, and there were no great differences between how well the screening methods identified patients and no significant differences between how well the interventions helped them reduce the severity of their drinking. What was intended to be a 'control' condition against which scientifically developed and longer interventions could shine, turned out instead to be the better option, reaping what clinical benefits there were at the lowest direct cost in money and time.

Implementation often needs specialist support; throughput low

Seeing the effectiveness of brief interventions as established in principle, the studies aimed to assess whether they would also work in normal practice. First issue was the feasibility of implementing such programmes with training, support and incentives of the kind that might routinely be available. In each setting, the intention was that usual staff would undertake screening and intervention, except for the longest intervention of the three, lifestyle counselling. In probation and emergency departments, this was delegated to a specialist alcohol worker provided by the SIPS project, an extra resource which mirrors how such programmes would probably be (and in emergency departments, commonly have been) implemented in routine practice. The project also undertook training, though for the briefer interventions this was minimal. Apart from research tasks, enough to enable screening involving an understanding of the 'standard drink' used by the study to assess alcohol consumption, and an hour on how to deliver the brief advice option. For these interventions too, no structured ongoing support and supervision is mentioned, except "Research staff and trainers will maintain regular contact with practices throughout the study period, including site visits and telephone support." http://dx.doi.org/10.1186/1471-2458-9-287 for the primary care study, though researchers and alcohol health workers may have been available to offer ad hoc support.

One possibly important way the studies departed from normal practice was that usual staff also undertook the research tasks involved in recruiting patients to the trial and collecting baseline information. Compared to brief screening and intervention, this must have been a relatively substantial extra burden, one which may have suppressed the numbers screened Little pre-screening data collection was required, but staff would have known that a positive screen would demand more explanation of the intervention study, obtaining consent and data collection. and offered intervention.

Broadly, each study found that while implementing the tested programmes was possible, at many sites researchers and specialist alcohol workers who had trained the staff had to help with screening and intervention. Workload pressures, lack of knowledge, and feeling there were insufficient back-up alcohol services, were common themes. In emergency departments and in probation, inability to implement was the norm. Incentivized with per patient payments, most primary care practices managed to implement fully, but still 4 in 10 were unable to do so. While the denominators in terms of overall patient and offender throughput are unknown, the numbers screened seem to have been small, equivalent to about 12 per emergency department per week, less than two per GP practice per week, and one or two a fortnight in each probation office – and this despite the intention that half or more of the sites would screen nearly all the adults they saw who were capable of participating in the trials.

These findings have two possible implications. The first is to cast doubt over the potential for screening and intervention in these settings – as implemented and resourced in the trials – to make a significant contribution not just to the welfare of the individuals actually screened, but to the nation's health; numbers reached may simply be too small. Reinforcing this doubt was the uncertainty over the resultant impacts on those who were screened and advised (of which more below). Second is the possibility that those recruited to the trials and screened were not representative of all who might have been, and therefore too the possibility that how they reacted would not be duplicated in a national programme with the leverage to ensure widespread implementation.

Of all the settings commonly associated with brief interventions, primary care has the greatest potential to reach the greatest numbers, partly because of its coverage, and partly because there is a national requirement and framework for paying practices to undertake this work. The evaluation of Scotland's national brief intervention programme confirmed the SIPS finding that, decisively influenced by financial incentives, implementation was more acceptable to staff and more likely to succeed there than in emergency departments. Based on the three health board areas where these figures were known, the great majority of brief alcohol interventions were delivered in primary care. Though not averse to these unexpected discussions of drinking, patients rarely said they made any difference.

With GP practices looking for ways to improve incomes, the national requirement to offer screening and intervention contracts certainly has generated more activity. So far implementation has however been patchy, 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.

FAST screening edges it

In relation to screening, results from the trials have been amalgamated in a conference presentation. Of the three methods tested, the FAST Alcohol Screening Test had the broadest applicability, in all three settings virtually equalling or bettering the alternatives in terms of its ability to identify risky drinkers. Generally only the first (about frequency of excessive drinking) of the four questions had to be asked, and the test picked up 8 in 10 of the risky drinkers who would have been picked up by the longer AUDIT questionnaire, itself an accurate way of identifying hazardous drinkers in the British primary care context.

Whether screening is best implemented universally or targeted at certain patients or appointments was answered in favour of universal screening, if the yardstick was identifying the greatest number of risky drinkers and not missing out people (around 4 in 10 were missed) who would have screened positive. The most stringent test took place in the GP practices, where the same methods were used for universal and targeted screening. There the targeted method started with fewer eligible patients (1274 v. 1717) yet ended up netting more AUDIT-positive risky drinkers (461 v. 439), because (as intended) it did reserve screening for patients who were more likely to be risky drinkers. However, over a quarter who would not have been targeted turned out to score as risky drinkers. In a targeted strategy, their drinking risks being ignored. On the assumption that a universal strategy truly would be universally implemented, this may be the decisive consideration. But if targeting screening – favoured by primary care staff – encourages more complete implementation, the balance could shift in its favour.

Minimal or extended advice – it doesn't matter because each is equally (in?)effective

The final link examined by the studies was how best to advise risky drinkers identified through screening. Once patients and offenders had been sorted in to risky drinkers who had agreed to join the intervention study, there was a remarkable uniformity in trends in their drinking. Six months later the proportions scoring as risky drinkers had fallen by 11%, 12 months later, by 16–17%. With one exception, on this, the primary yardstick used by the studies, an alcohol advice booklet plus a sentence or two of feedback alerting someone to their risky drinking was not improved on by adding more extended and individualised interventions. The exception was a fleeting extra reduction at six months among particularly heavy drinking offenders offered counselling. Given the many tests of significance made in the studies, this single finding may have breached the threshold of statistical significance purely by chance, but the concordance with reconviction data suggests a real effect. Even if this was the case among offenders, findings among the patients gave no grounds for triaging heavier drinkers in emergency or primary care settings to more extended brief advice.

As the researchers acknowledged, this does not mean the interventions were equally effective; they may have been equally ineffective. Without a no-intervention comparator, there is no way of knowing whether the interventions played any hand in the outcomes. Even before the interventions, 15–20% The figure is not available for probation. of emergency patients and nearly a third in primary care said they were trying to reduce their drinking. Apart from the possible reasons for the drinking reductions mentioned by the researchers, this in itself could account for the findings.

It cannot even be said that screening plus a sentence of feedback is all it takes to get whatever benefits are available. These came after patients and offenders were quizzed about their drinking and related problems and their readiness to do something about these, possibly thought-provoking interventions in themselves. Also, while what was intended in the interventions is clear, what was actually done is not. In particular, it seems reasonable to question whether brief feedback interactions really ended abruptly after a doctor, nurse or probation officer, had warned the person for whom they had welfare responsibilities that their drinking risked harm – that the recipients of this news did not respond and staff in turn respond back, in what could have become an interchange rivalling in length and perhaps exceeding in individualisation the brief advice option.

Reinforcing doubts over the impact of the interventions is the general finding that 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 signi ficant. 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 in alcohol brief intervention studies who received no or minimal intervention on average reduced their drinking by amounts comparable to those seen in the SIPs trials. Though the review which collated these findings did not single these out, the studies which offered only usual care to control patients often also registered such reductions.

Regarding primary care in particular, a synthesis of international research has convincingly shown that in controlled trials, brief intervention has led to greater reductions in drinking among risky drinkers than usual care or just asking about drinking, but left considerable doubt over whether such reductions would survive once intervention was 'scaled up' to practices in general, and applied by the general run of doctors to the general run of patients. These concerns applied no less to Britain, where the two positive trials demonstrated brief intervention's potential, but not necessarily that it would work in typical practices which themselves identified patients for intervention, and with patients not subject to the multiple selection gateways applied by the studies. The featured study, an attempt to answer the question about real-world impact, found that in these circumstances, recommended methods scientifically developed and tested were no more effective in reducing drinking and no more cost-effective in improving quality of life ( below) than a brief warning.

Where the longer interventions did score over this warning was in the impression they (or their offer) made on patients. Later they were more likely to claim they were trying to cut their drinking and the counselling patients were more satisfied with aspects of the intervention. Both make sense in ways which need bear no relation to whether patients actually did cut down. Patients seeing their GP or practice nurse who really were just told they were drinking at possibly harmful levels and offered no further advice might well have felt short-changed and uncared for, while those on whom the practice had (in primary care terms) 'lavished' several minutes or even more on their drinking might feel obliged at least to say they were trying to cut back.

Cost may be decisive

The clearest difference between the interventions was in cost, likely to be persuasive given equivocal or no evidence that spending more gained more. Not only did this directly cost least, but on the health service's primary yardstick – quality adjusted life years – in both probation and primary care, the briefest intervention gained most years for each £ of social costs incurred by the drinkers. Only in emergency departments did the longest intervention have the edge, but this was minimal, and may have been partly due to these patients starting the study with the lowest quality of the three intervention groups and catching up somewhat in a natural levelling up.

In the primary care study in particular, the advantage of the briefest of the interventions would presumably have become clearer as higher values were assigned to each good quality year of life. The £20,000 value used in the illustrative figures is at the lower end of estimates.

All quality of life calculations are partly dependent on how quality is measured. SIPS used a health-related measure, ill equipped to capture losses or gains in the quality of social and leisure life, major domains within which drinking plays a role and is seen by consumers to have value (for which they are prepared to pay), just as excessive drinking can cause damage. Discounting such possible benefits of substance use as judged by consumers also makes a substantial difference to cost-benefit calculations.

Policy implications

The UK alcohol strategy published in 2012 said government was awaiting the results of the SIPS project before deciding whether to incorporate alcohol screening and brief intervention in to the national quality framework for primary care, a major national driver of primary care practice. Already screening for risky drinking is among the practices commissioners must incentivize through cash rewards, and audit procedures are intended to ensure this is followed by brief interventions or referral for dependent drinkers. From April 2013 this work will be incorporated in the NHS Health Check for older adults. The strategy also encouraged accident and emergency departments and hospitals in general to check for and offer brief advice about hazardous drinking, in the case of hospitals by employing alcohol liaison nurses.

In general, all areas covered by the strategy are expected to implement guidance from the National Institute for Health and Clinical Excellence on prevention and treatment of drinking problems and associated quality standards and guidance for commissioners. These documents' insistence that commissioners and managers of NHS-commissioned services "must" ensure staff have enough time and resources to carry out screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and brief intervention Guidance explains that this can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). work effectively seems a tall order given the consistent appeal in the SIPS studies to workload pressures as a reason for incomplete implementation and the need for specialist support – and this in services which had volunteered to participate in the studies.

The guidelines' preferences for targeted screening may also need to be re-evaluated, though SIPS' findings on this issue are probably not definitive enough to override the greater feasibility of targeting due both to workload pressures and staff preferences. It seems questionable too whether the precision of the 10-item AUDIT screening questionnaire is sufficient to warrant the guidelines' preference for this as a first-line option, or as a triaging tool if a briefer screen is positive. The FAST method picked up 8 in 10 of the risky drinkers who would have been picked up by the AUDIT, and there was few signs of extra benefits from triaging higher risk patients to extended counselling. However, SIPS so far has nothing to say about whether AUDIT should still be used to identify, not higher risk drinkers for extended advice, but dependent drinkers for referral to treatment, the role envisaged in the reimbursement framework for screening by GPs in England.

Where guidance is clearly at odds with the findings is in its backing for the equivalent of the mid-level intervention, brief advice, and, subject to local conditions, the most extended option – motivationally based counselling – for heavier but probably still non-dependent drinkers. As highlighted by the Department of Health's Director of Health and Wellbeing, the appealing message from the studies is that "Less is more". On the face of it, the findings go even further than her presentation suggests, offering most consistent backing for merely informing patients of screening results. For reasons outlined above, this message may be misleading because much more was and may have been done. But with no convincing reason to spend more money and time, it is easy to imagine that hard-pressed staff and austerity-hit commissioners will do the least seemingly justified by studies on which the government itself said it would rely for its policy decisions.

Last revised 19 May 2012. First uploaded

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Alcohol screening and brief intervention in emergency departments.

Drummond C., Deluca P.
Institute of Psychiatry, King's College London, 2012.
Unable to obtain a copy by clicking title? Try this alternative source.

The emergency department arm of the largest alcohol screening and brief intervention study yet conducted in Britain found that the proportion of risky drinkers fell just as much after the most minimal of screening and intervention methods as after more sophisticated and longer (but still brief) alternatives.

Summary This account is based on preliminary findings released by the SIPS project in the form of factsheets and conference presentations rather than peer-reviewed publication in academic journals. In respect of the effectiveness of the brief interventions tested in the trial, these documents have now been partially superseded by formal journal publication of the results, a report also analysed for the Effectiveness Bank. Some of the preliminary reports to which links are provided may no longer be available on the SIPS project web site.

SIPS was funded by the UK Department of Health in 2006 to evaluate the effectiveness and cost effectiveness of different ways of identifying risky drinkers through routine screening, and different forms of brief advice to help them cut back. Other aims were to assess the feasibility of implementing such procedures in typical practice settings, and to discover what made these more or less likely to succeed.

Conducted in three English regions (London, the South East, and the North East), the project took the form of three randomised controlled trials in different types of settings: nine emergency departments; 29 GP surgeries; and 20 probation offices. After summarising common features across the three trials, this account focuses on the emergency department study, relying largely on a factsheet produced before formal publication of the findings.

All three trials involved random allocation of practices, departments or offender managers to different variants of screening and intervention. Staff seeing adult patients or offenders for usual purposes in these settings asked them to consent to screening and basic data collection. Those who screened positive were further asked to join the study of the interventions, usually The exception was the most intensive of the interventions in emergency departments and probation offices, intended to be reserved for specialist alcohol workers. to be delivered by the same staff after training by the study. To assess changes in their drinking and related issues, patients and offenders who were eligible for Across all three trials patients or clients already in treatment for drink problems were excluded as were those severely injured, suffering with a serious mental health problem, or who were grossly intoxicated or homeless. and agreed to participate in the intervention study were followed up six and 12 months later.

Screening methods

Three quick ways to identify risky drinkers were tested for feasibility and accuracy, the latter defined by how well they duplicated corresponding results from the AUDIT screening questionnaire, widely used to determine whether someone is probably drinking at hazardous, Scoring at least 8, the cut-off used by the study. harmful or possibly dependent levels.

Single question: The simplest and quickest method was to ask, "How often do you have eight (or for women, six) or more standard drinks Each drink is roughly a UK unit of 8gm alcohol. on one occasion?" Monthly or more was considered a positive screen, meaning the respondent would be offered a brief intervention to help them cut back.
FAST Alcohol Screening Test: As used in the study, this begins with the question above and registers a positive screen if the response is weekly or more often. Otherwise three further questions About how often in the last six months the respondent has been unable to remember what happened during the previous night's drinking, failed due to drink to do what was normally expected of them, or experienced concern over their drinking from a relative, friend, or health professional. are asked. Scores in response to the four questions are summed So that, for example, people who have (even if in all cases less than monthly) drunk excessively, and forgotten what happened and failed to meet obligations would screen positive, as would someone who said they had never drunk excessively yet had either forgotten or failed to meet obligations at least weekly, or experienced concern on more than one occasion. to determine whether to proceed with intervention.
Paddington Alcohol Test (PAT): Used only in the emergency department study, this version of a set of screening questions developed for this setting first asks the clinician whether the patient is a repeat attendee or has any of nine complaints Fall; collapse; head injury; assault; accident; unwell; non-specific gastro-intestinal; cardiac; psychiatric. most often found among alcohol-related emergency attendees. If not, the screen is negative and no further action is taken. If yes, the patient themself is asked the single question above (monthly is considered positive) and also whether they feel their attendance is drink-related (if so, the screen is positive). This form of screening is considered 'targeted' because only selected patients are questioned.

Interventions and assessing their impacts

Patients or offenders identified as risky drinkers by these methods were all offered advice of some kind, so the study could not assess the absolute impact of this advice, only how the impacts of one variant differed from those of another. The main yardsticks These figures were adjusted for any significant differences between the patients or offenders on characteristics the study found related to how likely they were to end up drinking safely. were the proportions of patients or offenders who six and 12 months later did not score as hazardous (or worse) drinkers on the AUDIT questionnaire, which assesses alcohol intake and other indicators of harmful or dependent drinking. Other assessments included drink-related problems, quality of life, and use of services. Crime and health service costs before the study and over the 12-month follow-up were used to assess cost effectiveness in terms of gains in quality-adjusted years of life per £ change in costs to society.

All the patients and offenders in the intervention trial were given a standard The UK Department of Health's How much is too much? booklet, was the standard official public information available at the beginning the SIPS project. alcohol information and advice booklet, supplemented by a sticker with contact information for local alcohol treatment services. At issue was whether also offering different types and degrees of advice would make a difference to later drinking.

Brief feedback: At its most basic, the booklet was accompanied only by very brief feedback from the health care or criminal justice practitioner who did the screening that the screening test had indicated the patient or offender was drinking "above safe levels, which may be harmful to you".
Brief advice: The next level supplemented booklet and feedback with five minutes of advice closely related to the content of the booklet. This was based on a leaflet which the worker left with the drinker after working through it with them according to a standard protocol, including comparison with population drinking levels. Though not always the case, ideally this would be seamlessly delivered by the person who did the screening and handed over the booklet.
Brief lifestyle counselling: The most intensive (but still brief) of the interventions added what was intended to be about 20 minutes of lifestyle counselling to the brief advice described above. This too was based on a leaflet, but practitioners could adapt the intervention to the needs of the drinkers and their willingness to think about further controlling their drinking. Staff were trained to use techniques from motivational interviewing and health behaviour change counselling to lead the drinker to consider the pros and cons of their drinking and their readiness to cut down, before if appropriate formulating a plan for doing so and overcoming possible obstacles. This counselling was done at an appointment In emergency and probation settings, appointments with specialist alcohol workers recruited for the studies. made after the brief advice phase of the intervention.

The emergency department study

This account also draws on a description of the study's methodology and a conference presentation of the findings. Each year over 14 million people are treated in English emergency departments. A third of attendances are related to drinking and others involve risky drinkers, offering a substantial opportunity to intervene. Additional to the project's general aims, the emergency department study tested a 'targeted' screening approach (the Paddington Alcohol Test) developed for emergency departments, which questioned only patients whose complaints or attendance records suggested excessive drinking. The other screening methods were to be applied to all eligible patients. Another feature was that while emergency clinicians would screen and deliver brief feedback and advice options, they were not intended to deliver the most intensive intervention, brief lifestyle counselling. Instead they were to make an appointment (usually for the next day) for the patient to see an alcohol health worker recruited for the study and based at the department who was both appropriately qualified Staff had to have a relevant professional qualification, a diploma in drug and/or alcohol studies or equivalent, five years post-qualifying experience with a minimum two years in an alcohol or drug speciality, and prior knowledge and understanding of psychological interventions, including motivational interviewing. and specially trained.

Main findings

Three each of nine Selected to have no existing programme of alcohol screening and brief intervention. departments in the study were randomly allocated to each of the three screening methods. Within these sets, one each was randomly allocated to follow screening with a different intervention. In the event and despite staff enthusiasm, only three departments managed to implement the trial as intended. A conference presentation documents that though staff were keen, implementation of the SIPS screening and brief interventions was “limited” in most departments due to workload pressures, lack of time, perceived lack of importance of alcohol in the emergency department, high staff turnover, competing priorities, and feeling forced to take on extra work. Only three of nine departments could implement the procedures without researchers and alcohol health workers having themselves to help with screening and intervention.

The result was that over 13 months, 5992 patients were screened, of whom 3737 were eligible to participate in the study. Of these, 1491 (4 in 10) screened positive and 1204 agreed to join the intervention study. Typically white men of whom half were single, they averaged 35 years of age and an AUDIT score of 12–13, a medium severity of drinking problems, though about a quarter scored as high severity. Around 70% were followed up six and 12 months later.

In terms of identifying people who screened positive for risky drinking on the AUDIT, the single question was best (81% were identified), followed by the FAST Alcohol Screening Test (80%) and finally the Paddington Alcohol Test (74%). Statistical testing indicated that the single question method was significantly better than the Paddington Alcohol Test at identifying people whose AUDIT scores indicated a medium severity Scores 8–15 inclusive. Higher scores represent a high level of alcohol problems; lower, non-hazardous drinking. of alcohol problems, the range thought appropriate for brief interventions.

Positive-screen patients were then to be offered one of the advice options. Virtually all allocated to brief feedback or advice received this plus the alcohol advice booklet, the full intended interventions. This was not the case for those allocated to brief lifestyle counselling; though nearly all received the five-minute brief advice and booklet delivered immediately after screening, only half kept an appointment with the alcohol health worker for further counselling.

Six and 12 months later the proportions of patients scoring as at least hazardous drinkers on the AUDIT questionnaire (initially about 78%) had fallen overall by nearly 11% and 16% respectively, but on this measure nor on the other main yardsticks (alcohol-related problems and health-related quality of life) had there been significantly greater changes after one type of intervention than another. The expected extra impacts of more intensive advice and counselling had not materialised; at 12 months the reductions were 19% after the least intensive brief feedback option and 15% after the other two. Neither The prior screening method through which the patient had been identified also made no difference to their later drinking. could it be shown that one intervention was preferable for particularly heavy drinkers. In fact, by 12 months the proportion scoring as high severity on AUDIT had fallen most steeply after the briefest of the interventions – by 10% compared to 5–6% after the other two.

Where there was a clear difference was in costs, averaging £1.75 for the brief feedback option, £10.27 for brief advice, and £33.87 for lifestyle counselling. Compared to the preceding period, after all three options patients less often attended emergency departments and were less likely to be admitted as hospital inpatients. Over the 12-month follow-up period, health care plus criminal justice cost savings were £1860 greater after lifestyle counselling than after brief feedback. Lifestyle counselling also resulted in greater gains in quality-adjusted life year than the less intensive options, though this finding was not statistically significant and these patients did not end up with a better quality of life than the other patients. Valuing each of these years at £20,000 and taking in to account all costs, not just those of the interventions, it meant there was a 50.4% probability that the lifestyle counselling intervention improved cost-effectiveness relative to the booklet plus very brief feedback of screening results.

The authors' conclusions

Though certainly possible, due to the exigencies of emergency care, implementing alcohol screening and brief intervention in these departments will be difficult, generally requiring delivery by specialist alcohol staff. Successful implementation also depends on local clinical and managerial champions and having a small number of staff dedicated to and responsible for delivery. Even when emergency staff themselves take on screening and intervention, sustained implementation is likely to required sustained and significant outside specialist support. Particularly difficult to implement was the lifestyle counselling intervention which required appointments to be made and kept, rather than the seamless delivery of briefer interventions actually in the emergency department.

In terms of screening, the single question option trialled by the study proved both the quickest and the best at identifying risky drinkers.

When it came to how to respond to these risky drinkers, the more intensive interventions offered no significant clinical benefits, even for heavier drinkers. On average all were followed by reductions in the severity of drinking, results which may have been due to the interventions, but may instead have been due to natural changes in relatively extreme behaviour, or to the impact of being repeatedly assessed for drinking and recruited to a trial of drinking interventions.

Though only half the patients allocated to this received it, the most intensive of the interventions (brief lifestyle counselling) led per £ spent to greater gains in quality of life and greater reduction in societal costs, advantages which might be augmented by more complete implementation.


Findings logo commentary See these Findings analyses for the sister trials conducted in GP surgeries and probation offices. The following commentary explores common themes across these settings and any differences, and supplements these with comments focused on the featured setting, emergency departments. The general picture was that implementation often required specialist support, and there were no great differences between how well the screening methods identified patients and no significant differences between how well the interventions helped them reduce the severity of their drinking. What was intended to be a 'control' condition against which scientifically developed and longer interventions could shine, turned out instead to be the better option, reaping what clinical benefits there were at the lowest direct cost in money and time.

Implementation often needs specialist support; throughput low

Seeing the effectiveness of brief interventions as established in principle, the studies aimed to assess whether they would also work in normal practice. First issue was the feasibility of implementing such programmes with training, support and incentives of the kind that might routinely be available. In each setting, the intention was that usual staff would undertake screening and intervention, except for the longest intervention of the three, lifestyle counselling. In probation and emergency departments, this was delegated to a specialist alcohol worker provided by the SIPS project, an extra resource which mirrors how such programmes would probably be (and in emergency departments, commonly have been) implemented in routine practice. The project also undertook training, though for the briefer interventions this was minimal. Apart from research tasks, enough to enable screening involving an understanding of the 'standard drink' used by the study to assess alcohol consumption, and an hour on how to deliver the brief advice option. For these interventions too, no structured ongoing support and supervision is mentioned, except "Research staff and trainers will maintain regular contact with practices throughout the study period, including site visits and telephone support." http://dx.doi.org/10.1186/1471-2458-9-287 for the primary care study, though researchers and alcohol health workers may have been available to offer ad hoc support.

One possibly important way the studies departed from normal practice was that usual staff also undertook the research tasks involved in recruiting patients to the trial and collecting baseline information. Compared to brief screening and intervention, this must have been a relatively substantial extra burden, one which may have suppressed the numbers screened Little pre-screening data collection was required, but staff would have known that a positive screen would demand more explanation of the intervention study, obtaining consent and data collection. and offered intervention.

Broadly, each study found that while implementing the tested programmes was possible, at many sites researchers and specialist alcohol workers who had trained the staff had to help with screening and intervention. Workload pressures, lack of knowledge, and feeling there were insufficient back-up alcohol services, were common themes. In emergency departments and in probation, inability to implement was the norm. Incentivized with per patient payments, most primary care practices managed to implement fully, but still 4 in 10 were unable to do so. While the denominators in terms of overall patient and offender throughput are unknown, the numbers screened seem to have been small, equivalent to about 12 per emergency department per week, less than two per GP practice per week, and one or two a fortnight in each probation office – and this despite the intention that half or more of the sites would screen nearly all the adults they saw who were capable of participating in the trials.

These findings have two possible implications. The first is to cast doubt over the potential for screening and intervention in these settings – as implemented and resourced in the trials – to make a significant contribution not just to the welfare of the individuals actually screened, but to the nation's health; numbers reached may simply be too small. Reinforcing this doubt was the uncertainty over the resultant impacts on those who were screened and advised (of which more below). Second is the possibility that those recruited to the trials and screened were not representative of all who might have been, and therefore too the possibility that how they reacted would not be duplicated in a national programme with the leverage to ensure widespread implementation.

In Scotland an evaluation of its national brief intervention programme has confirmed the SIPS finding that implementation faced greater barriers than in primary care. Based on the three health board areas where these figures were known, brief alcohol interventions were delivered to just over 6% of the estimated 100,000 alcohol-related attendances per year to Scottish emergency departments. Interviews with emergency department staff revealed that resistance to the programme (feeling that this was not their business and detracted from core activities and objectives) and time pressures sometimes led (contrary to the preferred option) to intervention being by appointment some time after screening rather than immediate, and this in turn reduced attendance rates.

FAST screening edges it

In relation to screening, results from the trials have been amalgamated in a conference presentation. Of the three methods tested, the FAST Alcohol Screening Test had the broadest applicability, in all three settings virtually equalling or bettering the alternatives in terms of its ability to identify risky drinkers. Generally only the first (about frequency of excessive drinking) of the four questions had to be asked, and the test picked up 8 in 10 of the risky drinkers who would have been picked up by the longer AUDIT questionnaire.

Whether screening is best implemented universally or targeted at certain patients or appointments was answered in favour of universal screening, if the yardstick was identifying the greatest number of risky drinkers and not missing out people (around 4 in 10 were missed) who would have screened positive. The most stringent test took place in the GP practices, where the same methods were used for universal and targeted screening. There the targeted method started with fewer eligible patients (1274 v. 1717) yet ended up netting more AUDIT-positive risky drinkers (461 v. 439), because (as intended) it did reserve screening for patients who were more likely to be risky drinkers. However, over a quarter who would not have been targeted turned out to score as risky drinkers. In a targeted strategy, their drinking risks being ignored. On the assumption that a universal strategy truly would be universally implemented, this may be the decisive consideration. But if targeting screening – favoured by primary care staff – encourages more complete implementation, the balance could shift in its favour.

Minimal or extended advice – it doesn't matter because each is equally (in?)effective

The final link examined by the studies was how best to advise risky drinkers identified through screening. Once patients and offenders had been sorted in to risky drinkers who had agreed to join the intervention study, there was a remarkable uniformity in trends in their drinking. Six months later the proportions scoring as risky drinkers had fallen by 11%, 12 months later, by 16–17%. With one exception, on this, the primary yardstick used by the studies, an alcohol advice booklet plus a sentence or two of feedback alerting someone to their risky drinking was not improved on by adding more extended and individualised interventions. The exception was a fleeting extra reduction at six months among particularly heavy drinking offenders offered counselling. Given the many tests of significance made in the studies, this single finding may have breached the threshold of statistical significance purely by chance, but the concordance with reconviction data suggests a real effect. Even if this was the case among offenders, findings among the patients gave no grounds for triaging heavier drinkers in emergency or primary care settings to more extended but still brief advice.

As the researchers acknowledged, this does not mean the interventions were equally effective; they may have been equally ineffective. Without a no-intervention comparator, there is no way of knowing whether the interventions played any hand in the outcomes. Even before the interventions, 15–20% The figure is not available for probation. of emergency patients and nearly a third in primary care said they were trying to reduce their drinking. Apart from the possible reasons for the drinking reductions mentioned by the researchers, this in itself could account for the findings.

It cannot even be said that screening plus a sentence of feedback is all it takes to get whatever benefits are available. These came after patients and offenders were quizzed about their drinking and related problems and their readiness to do something about these, possibly thought-provoking interventions in themselves. And, as the researchers acknowledged, while what was intended in the interventions is clear, what was actually done is not. In particular, it seems reasonable to question whether brief feedback interactions really ended abruptly after a doctor, nurse or probation officer, had warned the person for whom they had welfare responsibilities that their drinking risked harm – that the recipients of this news did not respond and staff in turn respond back, in what could have become an interchange rivalling in length and perhaps exceeding in individualisation the brief advice option.

Reinforcing doubts over the impact of the interventions is the general finding that 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 in alcohol brief intervention studies who received no or minimal intervention on average reduced their drinking by amounts comparable to those seen in the SIPs trials. Though the review which collated these findings did not single these out, the studies which offered only usual care to control patients often also registered such reductions.

Regarding emergency department in particular, the findings seem at odds with those from the best researched British programme at St. Mary's hospital in London, which screens suspected heavy drinkers or patients with complaints linked to heavy drinking. In the relevant study, doctors explained to all positive screen patients that drinking is damaging their health, then patients were randomly allocated to be given only an alcohol advice booklet, or offered an appointment with an on-site health worker for counselling – similar to the SIPS trial's comparison between brief feedback and lifestyle counselling. But the findings were not similar; offering counselling was found to further significantly reduce return visits to the department and later drinking, the latter more cost-effectively than brief feedback.

One possibly critical difference is that at St. Mary's the patients were typically very heavy drinkers and clearly dependent, averaging AUDIT scores three times those in SIPS. This too was the case in another UK study which found that an option similar to the SIPS counselling intervention led to much greater remission in dependence and drinking than assessment only.

Though the featured study found no extra benefit from counselling even in heavier drinkers, these studies suggest this may materialise further up the severity scale among drinkers dependent enough to warrant treatment, but who are not actually looking for that kind of help.

Cost may be decisive

The clearest difference between the interventions was in cost, likely to be persuasive given equivocal or no evidence that spending more gained more. Not only did this directly cost least, but on the health service's primary yardstick – quality adjusted life years – in both probation and primary care, the briefest intervention gained most years for each £ of social costs incurred by the drinkers.

Only in emergency departments did the longest intervention have the edge, but at normal valuations of a life year, this was minimal. It resulted partly from an extra increase in quality of life that itself failed to reach statistical significance, and may have been partly due to these patients starting the study with the lowest quality of the three intervention groups. Rather than ending the study with on average a better quality of life than the other patients, they caught up somewhat in what may have been a natural levelling up unrelated to the interventions. Even in the emergency setting, this finding offers no convincing basis for extending intervention beyond the simple warning and written advice of the brief feedback option.

All quality of life calculations are partly dependent on how quality is measured. SIPS used a health-related measure, ill equipped to capture losses or gains in the quality of social and leisure life, major domains within which drinking plays a role and is seen by consumers to have value (for which they are prepared to pay), just as excessive drinking can cause damage. Discounting such possible benefits of substance use as judged by consumers also makes a substantial difference to cost-benefit calculations.

Policy implications

The UK alcohol strategy published in 2012 said government was awaiting the results of the SIPS project before deciding whether to incorporate alcohol screening and brief intervention in to the national quality framework for primary care, a major national driver of primary care practice. Already, however, brief alcohol interventions are among the practices commissioners can incentivize through cash rewards, and from April 2013 this work will be incorporated in the NHS Health Check for older adults. The strategy also encouraged accident and emergency departments and hospitals in general to check for and offer brief advice about hazardous drinking, in the case of hospitals by employing alcohol liaison nurses.

In general, all areas covered by the strategy are expected to implement guidance from the National Institute for Health and Clinical Excellence on prevention and treatment of drinking problems and associated quality standards and guidance for commissioners. These documents' insistence that commissioners and managers of NHS-commissioned services "must" ensure staff have enough time and resources to carry out screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and brief intervention Guidance explains that this can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). work effectively seems a tall order given the consistent appeal in the SIPS studies to workload pressures as a reason for incomplete implementation and the need for specialist support – and this in services which had volunteered to participate in the studies.

The guidelines' preferences for targeted screening may also need to be re-evaluated, though SIPS' findings on this issue are probably not definitive enough to override the greater feasibility of targeting due both to workload pressures and staff preferences. It seems questionable too whether the precision of the 10-item AUDIT screening questionnaire is sufficient to warrant the guidelines' preference for this as a first-line option, or as a triaging tool if a briefer screen is positive. The FAST method picked up 8 in 10 of the risky drinkers who would have been picked up by the AUDIT, and there was few signs of extra benefits from triaging higher risk patients to extended counselling.

Where guidance is clearly at odds with the findings is in its backing for the equivalent of the mid-level intervention, brief advice, and, subject to local conditions, the most extended option – motivationally based counselling – for heavier but still probably non-dependent drinkers. As highlighted by the Department of Health's Director of Health and Wellbeing, the appealing message from the studies is that "Less is more". On the face of it, the findings go even further than her presentation suggests, offering most consistent backing for merely informing patients of screening results. For reasons outlined above, this message may be misleading because much more was and may have been done. But with no convincing reason to spend more money and time, it is easy to imagine that hard-pressed staff and austerity-hit commissioners will do the least seemingly justified by studies on which the government itself said it would rely for its policy decisions.

Last revised 09 July 2015. First uploaded 16 May 2012

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Alcohol screening and brief intervention in probation.

McGovern R., Newbury-Birch D., Deluca P. et al.
Institute of Psychiatry, King's College London, 2012.
Unable to obtain a copy by clicking title? Try this alternative source.

The probation arm of the largest alcohol screening and brief intervention study yet conducted in Britain found that the proportion of offenders drinking at risky levels fell just as much after the most minimal of screening and intervention methods as after more sophisticated and longer (but still brief) alternatives.

Summary This account has been superseded by an account based primarily on a later formally published report. It is retained here for archival purposes only. Please go to this analysis for the latest report.

The SIPS project

This account is based on preliminary findings released by the SIPS project in the form of factsheets and conference presentations rather than peer-reviewed publication in academic journals. Later more detailed and scientifically formal accounts of these and other findings (such as what was actually done by the interventionists and what patients thought of it) will be incorporated as they emerge, and mailing list subscribers will be alerted to any alterations in the findings or their implications. Some of the documents to which links are provided may no longer be available on the SIPS project web site.

The project was funded by the UK Department of Health in 2006 to evaluate the effectiveness and cost effectiveness of different ways of identifying risky drinkers through routine screening, and different forms of brief advice to help them cut back. Other aims were to assess the feasibility of implementing such procedures in typical practice settings, and to discover what made these more or less likely to succeed.

Conducted in three English regions (London, the South East, and the North East), the project took the form of three randomised controlled trials in different types of settings: nine emergency departments; 29 GP surgeries; and 20 probation offices. After summarising common features across the three trials, this account focuses on the probation study, relying largely on a factsheet produced before formal publication of the findings.

All three trials involved random allocation of practices, departments or offender managers to different variants of screening and intervention. Staff seeing adult patients or offenders for usual purposes in these settings asked them to consent to screening and basic data collection. Those who screened positive were further asked to join the study of the interventions, usually The exception was the most intensive of the interventions in emergency departments and probation offices, intended to be reserved for specialist alcohol workers. to be delivered by the same staff after training by the study. To assess changes in their drinking and related issues, patients and offenders who were eligible for Across all three trials patients or clients already in treatment for drink problems were excluded as were those severely injured, suffering with a serious mental health problem, or who were grossly intoxicated or homeless. and agreed to participate in the intervention study were followed up six and 12 months later.

Screening methods

Three quick ways to identify risky drinkers were tested for feasibility and accuracy, the latter defined by how well they duplicated corresponding results from the AUDIT screening questionnaire, widely used to determine whether someone is probably drinking at hazardous, Scoring at least 8, the cut-off used by the study. harmful or possibly dependent levels.

Single question: The simplest and quickest method was to ask, "How often do you have eight (or for women, six) or more standard drinks Each drink is roughly a UK unit of 8gm alcohol. on one occasion?" Monthly or more was considered a positive screen, meaning the respondent would be offered a brief intervention to help them cut back.
FAST Alcohol Screening Test: As used in the study, this begins with the question above and registers a positive screen if the response is weekly or more often. Otherwise three further questions About how often in the last six months the respondent has been unable to remember what happened during the previous night's drinking, failed due to drink to do what was normally expected of them, or experienced concern over their drinking from a relative, friend, or health professional. are asked. Scores in response to the four questions are summed So that, for example, people who have (even if in all cases less than monthly) drunk excessively, and forgotten what happened and failed to meet obligations would screen positive, as would someone who said they had never drunk excessively yet had either forgotten or failed to meet obligations at least weekly, or experienced concern on more than one occasion. to determine whether to proceed with intervention.
Paddington Alcohol Test (PAT): Used only in the emergency department study.

Interventions and assessing their impacts

Patients or offenders identified as risky drinkers by these methods were all offered advice of some kind, so the study could not assess the absolute impact of this advice, only how the impacts of one variant differed from those of another. The main yardsticks These figures were adjusted for any significant differences between patients or offenders on characteristics the study found related to how likely they were to end up drinking safely. were the proportions of patients or offenders who six and 12 months later did not score as hazardous (or worse) drinkers on the AUDIT questionnaire, which assesses alcohol intake and other indicators of harmful or dependent drinking. Other assessments included drink-related problems, quality of life, and use of services. Crime and health service costs before the study and over the 12-month follow-up were used to assess cost effectiveness in terms of gains in quality-adjusted years of life per £ change in costs to society.

All the patients and offenders in the intervention trial were given a standard The UK Department of Health's How much is too much? booklet, was the standard official public information available at the beginning the SIPS project. alcohol information and advice booklet, supplemented by a sticker with contact information for local alcohol treatment services. At issue was whether also offering different types and degrees of advice would make a difference to later drinking.

Brief feedback: At its most basic, the booklet was accompanied only by very brief feedback from the health care or criminal justice practitioner who did the screening that the screening test had indicated the patient or offender was drinking "above safe levels, which may be harmful to you".
Brief advice: The next level supplemented booklet and feedback with five minutes of advice closely related to the content of the booklet. This was based on a leaflet which the worker left with the drinker after working through it with them according to a standard protocol, including comparison with population drinking levels. Though not always the case, ideally this would be seamlessly delivered by the person who did the screening and handed over the booklet.
Brief lifestyle counselling: The most intensive (but still brief) of the interventions added what was intended to be about 20 minutes of lifestyle counselling to the brief advice described above. This too was based on a leaflet, but practitioners could adapt the intervention to the needs of the drinkers and their willingness to think about further controlling their drinking. Staff were trained to use techniques from motivational interviewing and health behaviour change counselling to lead the drinker to consider the pros and cons of their drinking and their readiness to cut down, before if appropriate formulating a plan for doing so and overcoming possible obstacles. This counselling was done at a later appointment made after the brief advice phase of the intervention, in emergency department and probation settings by specialist alcohol workers recruited for the studies.

The probation study

This account also draws on a description of the study's methodology and a conference presentation of the findings.

In 2007 in the UK there were about 950,000 incidents of alcohol-related violence, and drink is a factor in nearly half of all violent crimes. In Britain hazardous and harmful drinkers outnumber dependent drinkers 7:1. The greatest population-wide impact on alcohol-related problems can be made by identifying and intervening with these drinkers, even before they are aware of any problems or seek help. One proven way to do this is to screen for risky drinking and then offer brief advice to people who screen positive. However, questions remain about the best screening strategy, whether longer or more sophisticated interventions work better, impacts in normal practice, and cost effectiveness, all questions addressed by the overall design of the SIPs trial. One further gap is the lack of evidence on the impact of screening and brief interventions within the criminal justice system, a gap specifically addressed by the probation arm of the SIPS study.

Probation was chosen as the criminal justice setting on the basis of a pilot study of this setting plus prison and police stations. It found that offenders seeing probation officers were most likely to agree to join such a study, and that this setting offered the highest study recruitment rate. This pilot also found that offenders in these settings were three times as likely as the general population to be problem drinkers.

Across the North East, London and South East regions, 20 probation offices Selected to have no existing programme of alcohol screening and brief intervention. and 197 offender managers working in those offices agreed to join the study. Within each region, offender managers were randomly allocated to one of the six possible combinations of two screening methods (the single question and the FAST Alcohol Screening Test) to be applied to all eligible adult offenders, and the three interventions for those screening positive.

A slight methodological variation was that staff were first to give offenders the alcohol advice leaflet to read. At the next appointment, consent was sought for screening, screening was completed, and, for positive-screen offenders only, consent sought for the intervention phases of the study, brief feedback or advice given, and for offenders allocated to this, an appointment made to see the alcohol health worker for counselling.

Main findings

Despite staff enthusiasm, barriers to implementation cited by staff included workload pressures, lack of knowledge, and lack of follow-up treatment services. Compared to staff in the other two settings (primary care and emergency departments), screening and brief intervention was felt to meld more naturally with routine probation work, but staff were less convinced these procedures would be useful and tended to feel they were best reserved for offenders with obvious drinking problems. Of the 197 staff in the trial, 44 did not recruit any offenders to the study, and just 45 were able to implement screening and brief intervention as intended without extra help from researchers and the specialist alcohol workers. Implementation was more successful where research staff were able to engage with and provide ongoing support to individual staff and where they and the alcohol health workers were more often 'on site'.

In the end, over 16 months, 976 offenders were approached about the study of whom 860 were eligible to participate. Of these, 574 screened positive and 525 agreed to join the intervention study. Typically white men, they averaged 31 years of age and an AUDIT score at the threshold for a high severity Scores of 16 or more. Scores of 8–15 indicate medium severity and lower scores, non-hazardous drinking. of drinking problems, a range which accounted for 43%. Around two thirds were followed up six months later and 59% at 12 months.

In terms of identifying people who screened positive for risky drinking on the AUDIT, the FAST Alcohol Screening Test was preferable (92% were identified) to the single question (81%), and significantly better at identifying people whose AUDIT scores indicated a high severity of alcohol problems. The results confirm the (not statistically significant) trends in favour of FAST in the preceding pilot study in prisons and police stations as well as probation.

Positive screen offenders were then allocated to different forms of intervention. Virtually all allocated to brief feedback or advice received this plus the alcohol advice booklet, the full intended interventions. This was not the case for those allocated to lifestyle counselling; though nearly all received the five-minute brief advice and booklet delivered immediately after screening, only 41% attended a later appointment for more extended counselling.

Six and 12 months later the proportions of offenders scoring as at least hazardous drinkers on the AUDIT questionnaire (initially 82–90%) had fallen overall by 11% and nearly 16% respectively, but neither on this measure nor on alcohol-related problems or health-related quality of life had there been significantly greater changes after one type of intervention than another, and the offenders were equally satisfied with all the options. The expected extra impacts of more extensive advice and counselling had not materialised; at 12 months the reduction in the proportion of risky drinkers was 19% after the briefest option, 4–5% more than after the other two. However, at the six-month follow-up only, the high severity drinkers among the sample were significantly more likely (according to their AUDIT scores) to be drinking safely if they had been allocated to counselling rather than just brief feedback. Across the entire sample, police records also revealed that brief feedback offenders were significantly more likely to be reconvicted (50% v. 36–38%) than offenders offered either of the more extended interventions.

Another difference was in costs, averaging £1.04 per offender for the brief feedback option, £8.55 for brief advice, and £32.45 for lifestyle counselling. These costs were however overshadowed by the costs of the patients' health service use and crime over the 12 months of the follow-up. Changes in these costs from the period immediately before the offender joined the study meant that the most extensive option (the offer of counselling) saved society £2760 more than brief feedback. At the 12-month follow-up, all three groups registered slight declines in their average quality of life. Valuing each of these years at £20,000, there was a 98% probability that the briefest intervention was more cost effective than brief advice and 78% that it bettered the offer of more extensive counselling.

The authors' conclusions

Though possible, due to workload pressures, implementing alcohol screening and brief intervention in probation will be difficult. Successful implementation is associated with promotion by local managerial champions. Even then, successful and sustained implementation requires sustained and significant support from specialist alcohol workers. Particularly difficult to implement was the lifestyle counselling intervention, which required appointments to be made and kept rather than integrating screening and briefer interventions in to an existing probation supervision meeting.

In terms of screening, the Fast Alcohol Screening Test proved better than the single question at identifying risky drinkers.

When it came to how to respond to these risky drinkers, the more extensive interventions offered no significant clinical benefits, except temporarily at the six-month follow-up, when particularly high severity drinkers had responded better to counselling than brief feedback only. On average all the options were followed by reductions in the severity of drinking, results which may have been due to the interventions, but may instead have been due to natural changes in relatively extreme behaviour, or to the impact of being repeatedly assessed for drinking and recruited to a trial of drinking interventions.


Findings logo commentary See these Findings analyses for the sister studies conducted in emergency departments and GP surgeries. The following commentary explores common themes across these settings and any differences, and supplements these with comments focused on the featured setting, probation. The general picture was that implementation often required specialist support, and there were no great differences between how well the screening methods identified patients and no significant differences between how well the interventions helped them reduce the severity of their drinking. What was intended to be a 'control' condition against which scientifically developed and longer interventions could shine, turned out instead to be the better option, reaping what clinical benefits there were at the lowest direct cost in money and time.

Implementation often needs specialist support; throughput low

Seeing the effectiveness of brief interventions as established in principle, the studies aimed to assess whether they would also work in normal practice. First issue was the feasibility of implementing such programmes with training, support and incentives of the kind that might routinely be available. In each setting, the intention was that usual staff would undertake screening and intervention, except for the longest intervention of the three, lifestyle counselling. In probation and emergency departments, this was delegated to a specialist alcohol worker provided by the SIPS project, an extra resource which mirrors how such programmes would probably be (and in emergency departments, commonly have been) implemented in routine practice. The project also undertook training, though for the briefer interventions this was minimal. Apart from research tasks, enough to enable screening involving an understanding of the 'standard drink' used by the study to assess alcohol consumption, and an hour on how to deliver the brief advice option. For these interventions too, no structured ongoing support and supervision is mentioned, except "Research staff and trainers will maintain regular contact with practices throughout the study period, including site visits and telephone support." http://dx.doi.org/10.1186/1471-2458-9-287 for the primary care study, though researchers and alcohol health workers may have been available to offer ad hoc support.

One possibly important way the studies departed from normal practice was that usual staff also undertook the research tasks involved in recruiting patients to the trial and collecting baseline information. Compared to brief screening and intervention, this must have been a relatively substantial extra burden, one which may have suppressed the numbers screened Little pre-screening data collection was required, but staff would have known that a positive screen would demand more explanation of the intervention study, obtaining consent and data collection. and offered intervention.

Broadly, each study found that while implementing the tested programmes was possible, at many sites researchers and specialist alcohol workers who had trained the staff had to help with screening and intervention. Workload pressures, lack of knowledge, and feeling there were insufficient back-up alcohol services, were common themes. In emergency departments and in probation, inability to implement was the norm. Incentivized with per patient payments, most primary care practices managed to implement fully, but still 4 in 10 were unable to do so. While the denominators in terms of overall patient and offender throughput are unknown, the numbers screened seem to have been small, equivalent to about 12 per emergency department per week, less than two per GP practice per week, and one or two a fortnight in each probation office – and this despite the intention that half or more of the sites would screen nearly all the adults they saw who were capable of participating in the trials.

These findings have two possible implications. The first is to cast doubt over the potential for screening and intervention in these settings – as implemented and resourced in the trials – to make a significant contribution not just to the welfare of the individuals actually screened, but to the nation's health; numbers reached may simply be too small. Reinforcing this doubt was the uncertainty over the resultant impacts on those who were screened and advised (of which more below). Second is the possibility that those recruited to the trials and screened were not representative of all who might have been, and therefore too the possibility that how they reacted would not be duplicated in a national programme with the leverage to ensure widespread implementation.

In probation in particular, perhaps because risky drinking was so common (two thirds of offenders screened positive compared to a third of primary care patients), and because their interest was not in chronic long-term disease but in intoxication-related crime, probation officers were interested mainly in the most problematic drinkers, and it was these they tended to identify more than in the other settings. For more on screening, brief intervention and other alcohol-related work by probation in England and Wales see this Findings analysis, suggesting that while in theory widespread, screening is not the norm, and that on-site specialist alcohol workers are an important resource.

FAST screening edges it

In relation to screening, results from the trials have been amalgamated in a conference presentation. Of the three methods tested, the FAST Alcohol Screening Test had the broadest applicability, in all three settings virtually equalling or bettering the alternatives in terms of its ability to identify risky drinkers. Generally only the first (about frequency of excessive drinking) of the four questions had to be asked, and the test picked up 8 in 10 of the risky drinkers who would have been picked up by the longer AUDIT questionnaire.

In probation the advantage of the FAST test was clearer than in the other settings, perhaps because it asked questions about symptoms of the kind associated with intoxication-related impairment and lack of responsibility, but FAST may not meet the perceived need to identify high severity drinkers, for which AUDIT (the most commonly used screening tool in probation) may still be preferred. Whether screening is best implemented universally or targeted at certain offenders was not tested in the probation setting, but the prevalence of risky drinking was such that universal screening seems the most sensible option.

Minimal or extended advice – it doesn't matter because each is equally (in?)effective

The final link examined by the studies was how best to advise risky drinkers identified through screening. Once patients and offenders had been sorted in to risky drinkers who had agreed to join the intervention study, there was a remarkable uniformity in trends in their drinking. Six months later the proportions scoring as risky drinkers had fallen by 11%, 12 months later, by 16–17%. With one exception, on this, the primary yardstick used by the studies, an alcohol advice booklet plus a sentence or two of feedback alerting someone to their risky drinking was not improved on by adding more extended and individualised interventions.

The exception was in the featured probation study. At six months and among particularly heavy drinking offenders offered counselling, this study recorded a fleeting extra reduction in the proportion still drinking at risky levels. Given the many tests of significance made in the studies, this single finding may have breached the threshold of statistical significance purely by chance, but it seems possible that the on average higher severity of drink problems among the offenders meant that enough to register a statistically significant effect responded better to extended advice than to minimal feedback, feeding in to fewer reconvictions, and possibly too accounting for the relative reduction in health and crime costs associated with counselling. Even if this was the case among offenders, findings among the patients gave no grounds for triaging heavier drinkers in emergency or primary care settings to more extended brief advice.

As the researchers acknowledged, the general findings do not mean the interventions were equally effective; they may have been equally ineffective. Without a no-intervention comparator, there is no way of knowing whether the interventions played any hand in the outcomes. Even before the interventions, 15–20% The figure is not available for probation. of emergency patients and nearly a third in primary care said they were trying to reduce their drinking. Apart from the possible reasons for the drinking reductions mentioned by the researchers, this in itself could account for the findings.

It cannot even be said that screening plus a sentence of feedback is all it takes to get whatever benefits are available. These came after patients and offenders were quizzed about their drinking and related problems and their readiness to do something about these, possibly thought-provoking interventions in themselves. Also, while what was intended in the interventions is clear, what was actually done is not. In particular, it seems reasonable to question whether brief feedback interactions really ended abruptly after a doctor, nurse or probation officer, had warned the person for whom they had welfare responsibilities that their drinking risked harm – that the recipients of this news did not respond and staff in turn respond back, in what could have become an interchange rivalling in length and perhaps exceeding in individualisation the brief advice option.

Reinforcing doubts over the impact of the interventions is the general finding that 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 in alcohol brief intervention studies who received no or minimal intervention on average reduced their drinking by amounts comparable to those seen in the SIPs trials. Though the review which collated these findings did not single these out, the studies which offered only usual care to control groups often also registered such reductions.

Cost may be decisive

The clearest difference between the interventions was in cost, likely to be persuasive given equivocal or no evidence that spending more gained more. Not only did this directly cost least, but on the health service's primary yardstick – quality adjusted life years – in both probation and primary care, the briefest intervention gained most years for each £ of social costs incurred by the drinkers. Only in emergency departments did the longest intervention have the edge, but this was minimal, and may have been partly due to these patients starting the study with the lowest quality of the three intervention groups and catching up somewhat in a natural levelling up.

However, the featured probation study gives greater grounds in this setting for offering extended advice, especially among higher severity drinkers. Here the crime yardstick is more salient and though fleeting, the extra reduction in reconvictions at six months and the (possibly associated) lower social costs among high-severity offenders offered counselling may tip the balance. There is probably also a greater social expectation on staff working with convicted offenders to deliver more than a one-sentence warning, when failure to address drinking appropriately could result in serious crime.

All quality of life calculations are partly dependent on how quality is measured. SIPS used a health-related measure, ill equipped to capture losses or gains in the quality of social and leisure life, major domains within which drinking plays a role and is seen by consumers to have value (for which they are prepared to pay), just as excessive drinking can cause damage. Discounting such possible benefits of substance use as judged by consumers also makes a substantial difference to cost-benefit calculations.

Policy implications

The UK alcohol strategy published in 2012 said government was awaiting the results of the SIPS project before deciding whether to incorporate alcohol screening and brief intervention in to the national quality framework for primary care, a major national driver of primary care practice. Already, however, brief alcohol interventions are among the practices commissioners can incentivize through cash rewards, and from April 2013 this work will be incorporated in the NHS Health Check for older adults. The strategy also encouraged accident and emergency departments and hospitals in general to check for and offer brief advice about hazardous drinking, in the case of hospitals by employing alcohol liaison nurses.

In emergency departments and GP surgeries, the SIPS findings appear to contradict guidance recommending the equivalent of the mid-level intervention, or for heavier drinkers the most extended option. If anything, the findings offer most support for screening and brief feedback. Similar guidance has been disseminated to criminal justice services. However, in these settings, given the mixed findings from the SIPS probation trial on the relative impacts on drinking, quality of life, and crime and social costs, at the moment the findings seem to offer no convincing rationale for altering this advice in favour of a yet briefer option.

Last revised 19 May 2012. First uploaded

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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 2014 Alcohol screening and brief interventions for offenders in the probation setting (SIPS trial): a pragmatic multicentre cluster randomized 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 2011 Delivering alcohol brief interventions in the community justice setting: evaluation of a pilot project

STUDY 2012 Summary of findings from two evaluations of Home Office alcohol arrest referral pilot schemes

STUDY 2009 Evidence-based practice? The National Probation Service's work with alcohol-misusing offenders

STUDY 2012 Randomized controlled trial of mailed personalized feedback for problem drinkers in the emergency department: the short-term impact

STUDY 2011 Prison health needs assessment for alcohol problems





Screening and brief interventions (SBI) for unhealthy alcohol use: a step-by-step implementation guide for trauma centers.

Higgins-Biddle J., Hungerford D., Cates-Wessel K.
[US] Centers for Disease Control and Prevention and National Center for Injury Prevention and Control, 2009.

Based on research findings, a practical US government guide for trauma centres dealing with serious injuries on how to plan, implement and monitor a programme to identify risky drinking among their patients and to offer appropriate advice and referral.

Summary This guide is intended to help US trauma departments plan, implement, and continually improve the new Committee on Trauma alcohol screening and brief intervention requirements Level I and Level II trauma centres are required to have a mechanism to identify patients whose drinking is unhealthy, and Level I centres must have the capacity to help these patients. under four headings:
• Getting started: preliminary steps for planning and implementing an alcohol screening and brief intervention programme.
• Developing the programme: identification and help for patients with alcohol-related risk.
• Implementing the programme: adapting these ideas to your specific centre, including training and start-up.
• Maintaining and improving the programme: ensuring the best implementation of the final, agreed-on programme.

In the absence of routine alcohol blood testing the guide says that a single question about whether the patient has recently drunk five US standard drinks (about 14gm alcohol each drink) for men or four for women effectively determine who needs and who does not need a brief intervention. To determine whether the patient is dependent (so needs more extensive help) and whether their drinking is causing themselves or others problems (useful in helping them to consider cutting back), centres will need to decide which more detailed instrument to use as a follow-up.

With respect to interventions for identified risky drinkers, the guide says research has shown that brief interventions of differing types and lengths can be effective. As little as 3–5 minutes of simple advice from a healthcare professional has been shown to help many patients reduce their drinking. More extensive 15–20-minute sessions using a motivational interviewing approach have also been effective. Delivering brief advice is relatively easy to learn and takes less time, but the service may not be reimbursed for such a short service. Using 15–20 minutes of motivational interviewing requires somewhat more skill and takes more training and more time to deliver, but centres may be able to bill for it. Centres may want to decide which style of intervention they use based on whether they have staff experienced in motivational interviewing or willing to learn and provide the service.

Such programmes should be routinely monitored in terms of the proportion of patients targeting for screening who actually are screened, how many screen positive, how many of these are advised about their drinking, and what proportion who should have been referred for more extensive help actually were.


Findings logo commentary Unlike the fleeting contacts typical in emergency departments dealing mainly with minor conditions, US trauma centre patients have suffered life-changing events and injuries often associated with drinking, and are typically admitted for several days to the centre which organises their ongoing care. More so than in an emergency department, the situation patients find themselves in might in any event prompt a rethink about their drinking, and offers opportunities for effective alcohol interventions and for building therapeutic relationships with staff which may affect drinking. A major US study has investigated whether these advantages lead to extra reductions in drinking and related problems from a brief motivational intervention compared to minimal advice. For more on brief interventions and UK policy see this Effectiveness Bank hot topic.

Last revised 28 September 2015. First uploaded 08 May 2012

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

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

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

STUDY 2012 Alcohol screening and brief intervention in emergency departments

STUDY 2009 Does implementation of clinical practice guidelines change nurses' screening for alcohol and other substance use?

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

STUDY 2012 Text-message-based drinking assessments and brief interventions for young adults discharged from the emergency department

DOCUMENT 2011 Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults

HOT TOPIC 2015 Can brief alcohol interventions improve health population-wide?

REVIEW 2011 Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence





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