Re: Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial
ALCOHOL SCREENING AND BRIEF INTERVENTION
Is screening without intervention sufficient?
Sawitri Assanangkornchai, Associate Professor of Psychiatry(1), Patimoh Nima, PhD Candidate(1), J Guy Edwards, Visiting professor(1) and Emeritus consultant(2)
(1)Epidemiology Unit, Prince of Songkla University, Hat Yai, Thailand
(2)Royal South Hants Hospital, Southampton, UK
Kaner et al' s findings(1) that there is no evidence brief intervention provides significant additional benefit in reducing hazardous or harmful drinking, compared with just feedback after screening plus an information leaflet, has important implications for the delivery of an inexpensive, large scale adjunct to tackling the enormous problems resulting from alcohol-related disorders. We report here from Thailand evidence that tentatively supports these findings.
We have just completed a report on the introduction of the WHO-recommended Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) followed by brief intervention(2) into Thailand(3). The ASSIST differs from the Alcohol Use Disorders Identification Test (AUDIT) used in the Kaner et al study by screening for all substances misused and not just alcohol. In our study we added krathon (mitragynine speciosa, a plant with narcotic properties) to the drugs listed in ASSIST, as it is one of the most widely misused substances in Thailand. We reported the acceptability, uptake and difficulties in implementation of the procedure in Thailand and discussed them in relation to problems in developing countries.
A randomised controlled trial evaluating the effectiveness of ASSIST-liked brief intervention following screening compared with that of simple advice - just feedback of the ASSIST score and take-home, self-help material - was carried out in parallel with the above project, with outcomes assessed at three and six months. It will suffice to put on record here just some of the preliminary results at three months in support of Kaner et al's findings.
Of 507 patients who on screening were found to be at 'moderate risk' of substance misuse, and excluding those who used tobacco only, 245 were randomised into two groups - 123 who received ASSIST-linked brief intervention and 122 who received simple advice and patient information only. At three months follow-up there were no significant differences in the reductions in the ASSIST scores between the groups: the reductions in the alcohol group were 51% and 52% for the intervention and simple advice only groups, respectively, the corresponding reductions for other substances being 71% and 69%.
Like Kaner et al, we were concerned about the limitations of the study, which in our study included a possible additional Thai cultural bias due to a reluctance (perhaps greater than in more developed countries in which communities are more familiar with research) to disappoint or hurt those trying to help them, thereby giving overly favourable responses to questions regarding outcome. We agree with Murray's suggestion(4) that the results of Kaner et al could be due to both screening and screening plus intervention being equally effective or equally ineffective, with a regression to the mean effect, or due to the methodology being insufficiently sensitive to detect a significant difference between the groups. This would apply to our observations also. If we are to divert scarce resources from other services to screening and intervention procedures we need urgent answers to these uncertainties.
1. Kaner E, Bland M, Cassidy P, Coulton S, Dale V, Deluca P et al. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised trial. BMJ 2013: 346: e 8501
2. World Health Organization. The ASSIST project - Alcohol, Smoking and Substance Involvement Screening Test. Available at:
http://www.who.int/substance_abuse/activities/assist/en/index.html; 2009 [accessed 8.01.10]
3. Assanangkornchai S, Balthip Q, Edwards JG. Introducing the WHO-recommended screening-brief intervention procedure for smoking, excessive drinking and illegal substance misuse into a developing country: implementation, acceptability and uptake in Thailand. Submitted for publication.
4. Murray E. Screening and brief intervention for alcohol use disorders in primary care. Simple screening and provision of written information may be enough for most patients. BMJ 2013 345: e 8706.
Competing interests: No competing interests