Coulton S., Newbury-Birch D., Cassidy P. et al.
Alcohol and Alcoholism: 2012, 47(4), p. 423–427.
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At English prisons, police stations and probation offices, offenders and arrestees in this study usually scored as at least hazardous drinkers and over half as problematic on a drink problem survey; nearly all would have been identified by a much briefer screening method usually requiring just a single question.
Summary This is the report of a pilot study in 2007 which led to probation services being chosen as the site for the criminal justice arm of the SIPS project, 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 down. The corresponding arm of the main trial involved 20 probation offices; parallel trials were also conducted in emergency departments and GP surgeries.
Preparatory to the main trials the featured study tested the feasibility and acceptability of screening and delivering brief interventions in English criminal justice settings: three custody suites in police stations; three prisons; and three probation offices. At these locations routine criminal justice staff approached in total 592 detainees or offenders to see if they were eligible Aged 18 years or more, alert and orientated, resident in England and able to read and write English sufficiently to complete the survey. to join the study and if they were, to ask their consent to be screened for risky drinking.
Each participant who consented completed (in a randomised order) two quick screening methods involving staff asking them a set question or questions about their drinking and recording the results. The accuracy of these methods was tested by how well they duplicated corresponding results from same participants on 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.
The two screening methods were:
Single question: The simplest and quickest method was to ask, "How often do you have eight (or for women, six) or more
Each drink is roughly a UK unit of 8gm alcohol.
on one occasion?" Monthly or more was considered a positive screen, indicating that the respondent might benefit from an 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 the respondent is at risk from their drinking, so might benefit from an intervention to help them cut back.
Among the other questions asked of the participants were how useful they would find various types of alcohol advice, their willingness to engage in such an intervention, and whether they would feel under pressure to do so because of their current circumstances.
In probation offices 92% of offenders approached were eligible to join the study. In contrast, largely due to intoxication in police stations and poor literacy in prison settings, nearly two thirds could not join. Of those who could, around 90% consented in prison and probation but under a third in police stations. The net result was that of those originally approached, in probation 81% joined the study but in prison 36% and in police stations, just 10%.
Among these participants 73% exceeded the AUDIT test's threshold for hazardous drinking, including 54% of the total sample who tested as more severely affected drinkers already experiencing alcohol-related harm and possibly dependent. Compared to the remainder, AUDIT-positive drinkers were more often violent offenders, experienced poorer health, and had greater contact with health, social work and criminal justice services.
Compared to the AUDIT, the two screening methods differed in how many participants would have qualified or not for being offered advice on their drinking, but these differences were slight and not statistically significant. FAST best duplicated AUDIT results, identifying 96% (versus 91% for the single question method) of the risky drinkers identified by AUDIT, and not falsely identifying as risky drinkers 78% (versus 69%) of those below AUDIT's hazardous drinking threshold.
Just over half the risky drinkers identified by AUDIT had sought advice about their drinking in the past six months and nearly two thirds at some time. A third had sought advice from probation service offender managers but few (10% and 12%) from police or prison staff. Nearly 80% felt it would be useful to have immediate advice about drinking and roughly the same proportions said they would have been willing to receive five minutes of advice from staff at the site they were interviewed, or attend soon for 20 minutes of counselling by a specialist. Asked whether they would feel coerced to engage in an intervention for their alcohol use, three quarters said they would not.
In terms of the proportion of people approached who screened positive for risky drinking, probation services offered a higher 'yield' than prison or police custody suites. The latter were busy and often chaotic environments, screening at busy times was difficult, and many of those detained could not join the study because they were intoxicated. In prisons, poor literacy was the major impediment, but perhaps too enforced abstinence makes prisons less appropriate for brief interventions aimed at resolving ambivalence and fostering motivation, as opposed to more intensive, tailored interventions.
Offenders meeting their probation officers were most likely to be eligible to be screened using a valid screening instrument and to consent to screening. Across all settings, identified risky drinkers who had sought advice on their drinking were more likely to have done so from probation offender managers than from prison staff, suggesting that on this issue, probation was seen as a more legitimate source of advice. Encouragingly, three quarters of participants said they would not feel coerced into receiving an intervention.
Both brief screening interviews were acceptably accurate as defined by AUDIT results and can be considered suitable for these busy settings.
commentary This pilot study paved the way for the main trial in 20 probation offices across the North East, London and South East regions of England which recruited 525 risky drinking offenders. Despite probation appearing from the pilot study to be promising ground for the study, of the nearly 200 staff in the main trial, about a fifth did not recruit any offenders to the study, and only about a quarter were able to implement screening and brief intervention as intended without extra help from researchers and specialist alcohol workers. 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.
Confirming the trend in the featured pilot report, in the main trial too the FAST Alcohol Screening Test was preferable to the single question in terms of identifying people who screened positive for risky drinking on the AUDIT, and was significantly better at identifying people whose AUDIT scores indicated a high severity of alcohol problems. Both studies highlight the high frequency and severity of drinking problems among offenders.
The pilot study does however raise questions about the need for criminal justice to take on the task of identifying and offering brief advice to risky drinkers on health (as opposed to crime) grounds, if this is already being done at emergency departments, on hospital wards, and in GPs' surgeries, all of which the risky drinkers in the study seem generally to have visited in recent months. Also the report does not reveal to what degree screening merely confirmed what offender managers already know about the drinking of the offenders they were supervising.
Some information may already have been collected via the Offender Assessment System (OASys) applied to relatively serious offenders. Depending on the offender's profile, this includes questions about whether drinking influenced offending, how much and how often the offender drinks, whether this has been linked to violence, and their motivation to tackle any drink problems. However, it is often applied too late to influence sentences and not to less serious or low risk offenders, creating a gap within which screening might offer a valuable clue to whether excessive drinking should be addressed. Also its focus is on the crime connection, not the offender's need for alcohol advice and treatment on health or other grounds. When both were applied to probation clients in the north east of England, about 40% of cases classified as hazardous, harmful or possibly dependent drinkers on AUDIT were not identified by OASys. National guidance for England says offender managers should consider alcohol screening where OASys has not been completed or has not identified an alcohol problem but staff suspect alcohol misuse; AUDIT is recommended to assess severity.
The findings of the pilot and main trials referred to above cast doubt on whether such screening will be widely implemented, as did an audit of probation alcohol work which found that even among offenders known to be problem drinkers, under one in three had been screened using the AUDIT survey. The even briefer screens tested in the featured study might raise this somewhat without much loss of precision, but the saving in workload might be minimal because a follow-on AUDIT is recommended to assess the severity of problems among positive screen patients in order to arrange interventions in line with criminal justice guidelines.
Low recruitment to the featured study due to poor literacy in prisons seems to have been due to research requirements. Presumably it would not be an obstacle in normal practice because both screening methods involve staff reading out the questions and recording the answers.
Last revised 24 July 2012. First uploaded