Drug and Alcohol Findings home page in a new window Background notes

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

Longer treatment is not always better

The power of brief, clear, directive and authoritative advice and its ability to rival fully fledged treatment was first demonstrated in London in a study published in 1977 where male patients (with their partners) were attending a specialist alcohol unit for treatment. What half got was assessment plus a single session advising they were alcoholic and needed to abstain. They did as well as the other half offered the usual treatment at the time, which for two thirds of the men amounted to at least seven sessions. In both the US Project MATCH and the British UKATT trials of specialist alcohol therapies, on most measures relatively brief Four versus 12 sessions in MATCH, three versus eight in UKATT. motivationally based therapies equalled longer 12-step or cognitive-behavioural approaches. In Project MATCH, it was even the case that patients did not return for a single therapy session did almost as well as those who went through all 12 sessions of the study's most extensive therapies, and that nearly all the improvement there was going to be in drinking had occurred by week one, before most of the treatment had been delivered.

These and other findings (1 2 3 4 5 6 7) can be interpreted as a testament to the power of the situations and motivations which led these patients to seek treatment in the first place – not an explanation in the featured study, whose patients were seeking help with stomach, heart and other physical problems, not dependence on alcohol. The presumption is that instead their motivations to change their drinking were to resolve or avoid the worsening of these conditions, stimulated by the explicit link to drinking on which the counselling was based.

Does 'brief' work best with heavier drinkers in the emergency department?

Previous studies have shown that just a few minutes counselling risky drinking emergency patients can reduce consumption and alcohol-related injuries, improve welfare, promote treatment uptake, and cut the future workload of emergency services. But there have also been negative findings, and the research record is fairly evenly balanced between these and more positive findings. A synthesis of research on interventions conducted actually in the emergency department rather than after admission found that overall such interventions have not been shown to significantly reduce alcohol consumption, while impacts on drink-related problems have been variable. More positively, three studies did together indicate that six to 12 months after the interventions patients were half as likely as comparison patients to have suffered an alcohol-related injury, but all three were from the USA, and two involved only teenage patients whose drinking would have been illegal in that country.

In all three of these more positive studies, patients were known to have recently been drinking or had a history of drink problems rather than merely having tested as exceeding national drinking guidelines, underscoring the possibility that heavy drinkers are most affected by such interventions. This was the finding of a US study of an emergency department brief intervention which unusually did not exclude dependent drinkers, but recruited any injured patient who had drunk shortly before the injury, was drinking excessively, or showed signs of drink-related problems. In this study, only dependent drinkers benefited from the brief intervention. The amount drunk each week actually rose slightly more among non-dependent patients given counselling than those were not.

It makes sense that drinkers with the greatest need to change and recently reminded of that in a way which caused them to seek emergency medical care would be most responsive to advice to cut down or stop drinking. These findings are however not universal. Notably in a large national US trial, it was the lighter drinking and non-dependent patients who responded best to brief counselling, while heavier and probably dependent drinkers cut back little in relation to how heavy their drinking was to start with. Among these patients, brief counselling made no more impact than merely being assessed and handed a list of referral options.

Another factor is that patients who are patently drinking excessively may be more likely to admit to themselves that their hospital visit was due to drinking. In the featured study, this link was reinforced by the counselling. Rather than actual severity of drinking, it could be that patients who see this as the cause of their injury or illness are more receptive to alcohol counselling, and that such a perception is most likely among heavier drinkers. Perceptions seemed the critical factor in a study of the impact on risky drinking emergency department patients in Australia of mailed feedback confirming how excessive their drinking was. Only patients who explicitly attributed their medical misfortune to drinking or had good reason to so (because they had recently drunk before having to go to hospital) responded to the feedback by curbing their consumption. Given other studies, the analysts reasoned that probably the perception that their problems were related to drinking was the salient factor.

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