Screening and brief intervention for alcohol use disorders in primary careBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.e8706 (Published 09 January 2013) Cite this as: BMJ 2013;346:e8706
- Elizabeth Murray, reader in primary care
Excess alcohol consumption is a growing public health problem, causing around 5.3% of deaths in those aged under 60 years worldwide.1 In England, about one in four adults aged 16-65 (about seven million people) drink hazardously or harmfully.2 Alcohol accounts for 10% of disability adjusted life years (DALYs) and costs to the NHS of around £3bn (€3.7bn; $4.8bn) each year.3 High alcohol consumption is one of the top modifiable risk factors for premature morbidity and mortality, along with smoking and hypertension, yet much less research has been done on alcohol use disorders than on smoking or hypertension. The publication of Kaner and colleagues’ linked paper (doi:10.1136/bmj.e8501), which reports the findings of the SIPS (Screening and Intervention Programme for Sensible drinking) trial in primary care, is therefore welcome.4
Although screening and brief intervention reduce alcohol consumption by 15-30% for at least 12 months,5 6 it is unclear what the “brief intervention” should comprise and how “brief” it can be and still be effective. Kaner and colleagues’ large well conducted pragmatic cluster randomised controlled trial aimed to determine the effectiveness of different brief intervention strategies in reducing hazardous or harmful drinking in primary care.
The trial compared the effectiveness of three interventions, each of which built on the previous one. These consisted of a patient information leaflet control group, the addition of five minutes of structured brief advice, and the extra addition of 20 minutes of brief lifestyle counselling based on motivational interviewing techniques. The outcome was the proportion of participants who scored less than 8 on the alcohol use disorders identification test (AUDIT) at six months. This proportion increased in all three arms, with no difference between arms. Participants allocated to the most intense intervention reported slightly greater satisfaction with treatment and slightly increased readiness to change than those in the other two arms. The importance of this is unclear, given that reported readiness to change does not seem to correlate with subsequent behaviour change.7 8
How should policy makers and practitioners interpret these results? There are at least three possible explanations for the similar benefit seen in all three arms. The first is that all three arms included “active” interventions. Active components include the act of screening and identifying people as potential excessive drinkers, and the use of assessment tools at baseline. Simple completion of the AUDIT questionnaire has been shown to result in a reported 15-20% reduction in alcohol consumption at follow-up,9 10 and the results in the control (patient information leaflet) arm of the SIPS trial are compatible with this. A second explanation is that the trial could have failed to identify a difference in effect between arms because of methodological flaws—for example, the health professionals in the control arm may have accompanied delivery of the leaflet with advice and feedback. Thirdly, all three interventions could have been ineffective, and all changes could result from regression to the mean. We cannot tell which of these explanations is responsible for the results, although publication of the planned process data may help identify any methodological flaws. But it is important to know why all three arms showed similar benefit so that policy makers and commissioners of healthcare can decide whether to invest in screening and brief intervention.
The researchers argue that the study’s findings are most likely to be explained by the first option. If this is so, policy makers and practitioners should focus on screening and identifying problem drinkers, with simple feedback and provision of written information, rather than on delivering more complex interventions that require more practitioner time and a greater level of skill. This approach may help close the international evidence-practice gap in alcohol services.2 11 12
Some patients will probably need more extensive interventions, and emerging data suggest that a stepped care pathway, which provides more intensive care to those who want or need it, may be the most cost effective approach.13 This model of referring those with greater need to specialist services would fit well in primary care and could be relatively easy to implement.
Cite this as: BMJ 2012;345:e8706
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.