Effectiveness of brief interventions in primary care populations

Excessive drinking contributes significantly to social problems, physical and psychological illness, injury and death. Hidden effects include increased levels of violence, accidents and suicide. Most alcohol-related harm is caused by excessive drinkers whose consumption exceeds recommended drinking levels, not the drinkers with severe alcohol dependency problems. One way to reduce consumption levels in a community may be to provide a brief intervention in primary care over one to four sessions. This is provided by healthcare workers such as general physicians, nurses or psychologists. In general practice, patients are routinely asked about alcohol consumption during registration, general health checks and as part of health screening (using a questionnaire). They tend not to be seeking help for alcohol problems when presenting. The intervention they are offered includes feedback on alcohol use and harms, identification of high risk situations for drinking and coping strategies, increased motivation and the development of a personal plan to reduce drinking. It takes place within the time-frame of a standard consultation, 5 to 15 minutes for a general physician, longer for a nurse.

A total of 29 controlled trials from various countries were identified, in general practice (24 trials) or an emergency setting (five trials). Participants drank an average of 306 grams of alcohol (over 30 standard drinks) per week on entry to the trial. Over 7000 participants with a mean age of 43 years were randomised to receive a brief intervention or a control intervention, including assessment only. After one year or more, people who received the brief intervention drank less alcohol than people in the control group (average difference 38 grams/week, range 23 to 54 grams). For men (some 70% of participants), the benefit of brief intervention was a difference of 57 grams/week, range 25 to 89 grams (six trials). The benefit was not clear for women. The benefits of brief intervention were similar in the normal clinical setting and in research settings with greater resources. Longer counselling had little additional benefit.

Authors' conclusions: 

Overall, brief interventions lowered alcohol consumption. When data were available by gender, the effect was clear in men at one year of follow up, but not in women. Longer duration of counselling probably has little additional effect. The lack of evidence of any difference in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care. Future trials should focus on women and on delineating the most effective components of interventions.

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Background: 

Many trials reported that brief interventions are effective in reducing excessive drinking. However, some trials have been criticised for being clinically unrepresentative and unable to inform clinical practice.

Objectives: 

To assess the effectiveness of brief intervention, delivered in general practice or based primary care, to reduce alcohol consumption. To assess whether outcomes differ between trials in research settings and those in routine clinical settings.

Search strategy: 

We searched the Cochrane Drug and Alcohol Group specialised register (February 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), CINAHL (1982 to February 2006), PsycINFO (1840 to February 2006), Science Citation Index (1970 to February 2006), Social Science Citation Index (1970 to February 2006), Alcohol and Alcohol Problems Science Database (1972 to 2003), reference lists of articles.

Selection criteria: 

Randomised controlled trials, patients presenting to primary care not specifically for alcohol treatment; brief intervention of up to four sessions.

Data collection and analysis: 

Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, sub-group, sensitivity analyses, and meta-regression were conducted.

Main results: 

Meta-analysis of 22 RCTs (enrolling 7,619 participants) showed that participants receiving brief intervention had lower alcohol consumption than the control group after follow-up of one year or longer (mean difference: -38 grams/week, 95% CI: -54 to -23), although there was substantial heterogeneity between trials (I2 = 57%). Sub-group analysis (8 studies, 2,307 participants) confirmed the benefit of brief intervention in men (mean difference: -57 grams/week, 95% CI: -89 to -25, I2 = 56%), but not in women (mean difference: -10 grams/week, 95% CI: -48 to 29, I2 = 45%). Meta-regression showed little evidence of a greater reduction in alcohol consumption with longer treatment exposure or among trials which were less clinically representative. Extended intervention was associated with a non-significantly greater reduction in alcohol consumption than brief intervention (mean difference = -28, 95%CI: -62 to 6 grams/week, I2 = 0%)