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Rethinking brief interventions for alcohol in general practice

BMJ 2017; 356 doi: (Published 20 January 2017) Cite this as: BMJ 2017;356:j116

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Screening and brief intervention (SBI) can be patient-centred; but uptake is often low and/or poor quality; the question is does SBI improve health? Regardless, alcohol must still be addressed

Rice notes we did not mention efforts where uptake of alcohol brief intervention has not been low. He also points out that the teaser headline on the BMJ cover was misleading and simplified a complex problem. I agree with the latter. Regarding uptake, it is certainly true that national programs—in the US at Veterans hospitals where there are performance incentives, in others where specific practitioners are funded to deliver the service, and in Scotland where performance targets were set (among other strategies)—have achieved large numbers of reported screenings and brief interventions [1-3]. But even in these circumstances when substantial efforts are made, and even assuming that documentation of a brief intervention means that one was actually done, screening is often poor quality, and brief interventions likely do not retain their effectiveness [1,4]. And in careful evaluations of implementation, uptake is indeed quite low (e.g. single digit percentages screened even with training and financial reimbursement)[5]. Since we have little evidence that brief interventions affect anything beyond self-reported consumption in efficacy trials, one must raise legitimate questions regarding large implementation efforts that aspire to retain effectiveness in real practice. The question is not how many brief interventions can be reported to have been done; it remains to be demonstrated that dissemination of brief intervention can retain efficacy and improve health.

Wåhlin raises the idea that alcohol can only be discussed when it is relevant to a disease a patient has or if it interferes with the treatment of something. He suggests that a visit with a physician is only patient-centred in the context of patient motives and expectations and that therefore it is only after differential diagnosis that alcohol can be discussed, if relevant. Certainly alcohol must be relevant to the patient for it to be discussed but I disagree that the only way for it to be relevant is for it to be related to a disease the patient has or a treatment they are undergoing. I also recognize that there may be international cultural differences in the role responsibility of physicians and general practice.

At least in the US, prevention (universal, formerly known as primary) is well within the ken of the generalist primary care clinician. As such, the patient has an expectation that they will be screened for risks and diseases (e.g. colon cancer, breast cancer, cervical cancer; patients often request these) and even receive medications with risks for conditions they do not have (prophylaxis)(e.g. aspirin to prevent heart attacks) and treatments for asymptomatic diseases they didn’t know they had (high blood pressure). In fact many screenings (e.g. listening to the heart, counting the number of respirations or taking a temperature at every visit that have no known value) are done routinely despite not having known value or being related to patient disease or treatment. These may not be “relevant” in the sense that the patient has no symptoms or doesn’t have any connection to them, but they (at least the evidence-based ones) are relevant or can easily be made relevant to the patient who wishes to remain in good health.

Alcohol screening, and then advice given based on the results, is similar to cholesterol screening, depression screening, obesity screening and other health promotion activities. Once a screening suggests excessive alcohol use, skilled counseling can make the risks relevant to the patient. Alcohol screening was again recently ranked as one of the most impactful and cost-effective services, third after childhood immunizations and tobacco prevention—there is no argument that those are patient-centred services [6]. This preventive approach seems quite patient centered, at least when patients expect and are interested in prevention and health maintenance. The real reason alcohol screening is often not taken up in clinical care is more likely to do with the fact that drinking alcohol is normative behavior, clinicians have not viewed it as a risk factor in their domain, there is confusion about what level is risky, and alcohol use disorders are stigmatized, not that they do not fit with patient-centred care.

Several commenters raised issues regarding addressing dependence (not a preventive service expected to respond to brief intervention alone). It is certainly true that when screening, an important minority of patients with dependence are identified and they need to be addressed. AA referral is clearly an option for those with dependence and while beyond the scope of this brief comment, there is in fact a large literature on effectiveness even including randomized trials of referral even if not RCTs of the intervention of AA itself. But Andreasson has the right idea—we do not want to limit our interventions for dependence to referral (to AA or specialty treatment)—much can likely be done from repeated brief counseling to medication treatments in general practice settings.

There are many reasons to identify unhealthy alcohol use beyond the possibility of intervening with prevention or treatment. To diagnose just about any symptom, to treat with medications, and to manage chronic conditions, one needs to know about alcohol and other drug use, just as one needs to know about medications and allergies. And we need to be prepared to address unhealthy alcohol use in those who are ready to make changes. So many of the tools of SBI remain quite relevant to practice even if a single brief intervention does not improve health in and of itself.

In sum, if alcohol brief interventions are effective, they can fit the patient-centred agenda. Further, it does appear we can increase the number of brief interventions in health systems. What we don’t know is if they make a difference for health (whether they retain any efficacy or improve the health of populations). Studies (as we cited) raise serious questions about whether they do. That said, it does remain important, as Andreasson points out, that clinicians be prepared to address the spectrum of unhealthy alcohol use from hazardous use to dependence.

1. Williams EC, Rubinsky AD, Chavez LJ, et al. An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration. Addiction 2014;356:1472-81. doi:10.1111/add.12600 pmid:24773590.
2. Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ, Kivlahan DR. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am J Manag Care. 2006;12:597-606.
3. Madras BK, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99(1–3):280–295. 
4. Bradley KA, Lapham GT, Hawkins EJ, Achtmeyer CE, Williams EC, Thomas RM, Kivlahan DR. Quality concerns with routine alcohol screening in VA clinical settings. J Gen Intern Med. 2011a;26:299–306.
5. Anderson P, Bendtsen P, Spak F, et al. Improving the delivery of brief intervention for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial. Addiction. 2016;111:1935–1945.
6. Maciosek MV, LaFrance AB, Dehmer SP, et al. Updated priorities among effective clinical preventive services. Ann Fam Med. 2017;15(1):14–22.

Competing interests: Payment as an editor for BMJ, JAMA, J Addiction Med, UpToDate, American Society of Addiction Medicine and as a speaker to nonprofits and universities on related topics.

20 March 2017
Richard Saitz
Chair and Professor
Department of Community Health Sciences, Boston University School of Public Health
801 Massachusetts Avenue, Ste 433