The Management of Harmful Drinking and Alcohol Dependence in Primary Care A national clinical guidel

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The Management of Harmful Drinking and Alcohol
Dependence in Primary CareA national clinical
guidelineScottish Intercollegiate Guidelines
Network (SIGN)
www.sign.ac.uk
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Brief intervention - recommendations
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COCHRANE REVIEWEffectiveness of brief alcohol
interventions (BI) in primary care
populations.Kaner EFS, Dickinson HO, Beyer F,
Pienaar E, Campbell F, Schlesinger C, Heather N,
Saunders J, Burnand B. April 2007

• 24 Primary Care Studies, 5 Emergency Dept
  Studies 7,619 participants 1 year outcomes
• Mostly screening by telephone, or in clinic as
  soon as patients registered for their
  appointment,
• BI? lower alcohol consumption than controls after
  follow-up of one year or longer (mean difference
  -38 grams/week, 95 CI -54 to -23),
• Substantial heterogeneity between trials
• Sub-group where gender given (8 studies, 2,307
  participants) BI NOT effective in women (mean
  difference -10 grams/week, 95 CI -48 to 29, I2
  45).

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Caution 1 The gap between Can it work? and
Will it work? (efficacy v. effectiveness or
external validity) (Heather and Wallace,
Alcohol Concern Research Review, 2003)

• Can findings from 2- and 3- step screening and
  assessment procedures, yielding homogeneous,
  compliant and researchable groups, with dedicated
  therapists and research funding, be extrapolated
  to routine general practice?
• The Cochrane Review(2007) did not find that
  studies they classed as effectiveness studies
  had worse results ( but ? Appropriate
  classification?)

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A Pragmatic clinical trial - Screening and brief
intervention targeting excessive drinkers in
Danish general practice Beich et al, Alcohol
Alcoholism, 2007, 42, 593-603

• 39 Danish GPs (out of 426 invited)
• Systematic screening of 6897 eligible adults ?
  906 risky drinkers
• Research follow-up on 537 at 1214 months.
• Results
• Patient acceptance of screening and intervention?
  
• 10.3 (794 / 7,691) explicitly refused screening.
  
• All intervention group subjects (N 442) were
  exposed to an instant brief counselling session.
  17.9 of them (79/442) attended a follow-up
  consultation offered by their GP.
• Consumption Changes? At one-year follow-up,
  average weekly consumption had increased by 0.7
  drinks in both comparison groups.

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Blocks to GPs action

• Sceptical about the benefits or validity of
  screening
• Fear that patients may react badly to questions
  about alcohol
• It takes too long
• Feel they do not have specialist back-up

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Screening demands on the GP
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Realism

• To provide all the preventive services
  recommended by the US Preventive Services Task
  Force would take 7.4 hours of the working day of
  the average primary care physician Yarnall et al,
  Am J Pub Hlth, 2003 93,635-41

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Screen everyone? e.g. Anderson Scott Br J
Addict 1992, 87, 891-900
i.e. 1.8 of those screened entered the treatment
arm
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Screening ALL patients?

• Screening in GP if 5 of screened meet the
  criteria (drinking above low-risk not already
  in treatment not severely dependent)
• And NNT 8 (from systematic reviews etc)
• Then, 160 patients need to be screened to have
  one patient reduce to low-risk drinking who would
  not have reduced without intervention

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When to screen - SIGN Recommendation

• Case detection based on clinical presentation (36
  listed!), with judicious use of questionnaire
  tools and blood tests where there is suspicion
• ( rather than the screening of whole primary care
  populations)
• Plus
• The New Patient Registration
• The ante-natal clinic

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Scottish Government 1

• Scottish Enhanced Services (ES) in GP Practices
  (2007) Screen opportunistically patients with
  at-risk presentations (selected from SIGN
  Annex), using FAST questionnaire to identify
  those with hazardous and harmful drinking
• Mental health anxiety /depression/substance
  misuse
• Fatigue/malaise/dizziness/All injuries
• GI presentations
• Projected therefore GP is screening about 1
  in 5
• 25 might screen positive,
• ES for alcohol will be taken up by Fife, Forth
  Valley, Glasgow, Tayside, Orkney and Shetland

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Scottish Government 2

• Health Improvement Targets for 2008 (HEAT) H4
• Achieve agreed number of screenings using the
  setting-appropriate screening tool and
  appropriate alcohol brief intervention, in line
  with SIGN 74 guidelines by 2010/11
  http//www.scotland.gov.uk/Topics/Health/NHS-Scotl
  and/17273/targets/target-1

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Caveats

• does this surrender to a practice in which
  advice and help is offered only when it is
  already too late to prevent harm
• Efficacy of opportunistic screening needs
  demonstrating (but there appear to be many
  alcohol-ill patients who, when they first
  presented an at-risk clinical picture, were not
  specifically counselled or so they say later)

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Anticipatory Care

• Imaginative use of screening at times when people
  are already seeking help
• (Different from boltedon health promotion and
  screening as a separate operation from
  demand-led care)
• Hart JT, BMJ, 2008, 336, p.123

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The Single Most Important PointHealth workers
should have the skills to raise sensitive
lifestyle matters like smoking, alcohol, diet and
exercise, where appropriate and consonant

• ..being in agreement or harmony  free from
  elements making for discord

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Per 1000 patients screened, 2.6 would reduce
their drinking to low-risk (Beich, Thorsen and
Rollnick BMJ 2003 327 536-40 Prolific debate!!
http//www.bmj.com/cgi/eletters/327/7414/53636281
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COCHRANE REVIEWEffectiveness of brief alcohol
interventions in primary care populations.Kaner
EFS, Dickinson HO, Beyer F, Pienaar E, Campbell
F, Schlesinger C, Heather N, Saunders J, Burnand
B. April 2007

• Feedback on alcohol use and harms, identification
  of high risk situations for drinking
• coping strategies, increase motivation,
• 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.

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Caution 2 Lack of long term data

• Australian arm of the seminal WHO screening and
  BI study
• No difference in drinking between intervention
  group and controls at 10 years
• Wutzke et al, Addiction, 2002, 97, 665-75

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Number Needed to Screen NNS

• Screening all attenders at the practice, or
  practice list populations
• Three British studies in this literature, which
  reported number screened
• Maximum 1.8 of those screened met criteria and
  entered the treatment arm

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An evaluation of National Alcohol Screening Day
(NASD).Aseltine RH Jr, Schilling EA, James A,
Murray M, Jacobs DG. Alcohol Alcoholism. 2008
4397-103.

• Lobbies and common areas of community health
  centres and a retail mall
• Intervention (N 318) recruited at the NASD
  event, BI
• Control (N 395) recruited at same locations
  approximately 1 week after NASD.
• 66 follow-up at 3 months
• Among at-risk drinkers, NASD participants
  averaged approximately 5.6 fewer drinks per week
  than at-risk controls.
• At 3 Months , AT RISK DRINKING
• NASD 27 CONTROLS 43
• CONCLUSIONS exposure to a brief screening
  program with provision of feedback can result in
  significant reductions in alcohol consumption
  among risky drinkers.

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Evaluation of a telephone-based stepped care
intervention for alcohol-related disorders A
randomized controlled trial.Bischof G, Grothues
JM, Reinhardt S, Meyer C, John U, Rumpf HJ. Drug
Alcohol Depend. 2008 Mar 193(3)244-51

• METHODS Participants were proactively recruited
  from general practices in two northern German
  cities. In total, 10,803 screenings were
  conducted (refusal rate 5). Alcohol use
  disorders according to DSM-IV were assessed with
  the Munich-Composite International Diagnostic
  Interview (M-CIDI).
• Eligible participants were randomly assigned to
  one of three conditions (1) stepped care (SC) a
  computerized intervention plus up to three 40-min
  telephone-based interventions depending on the
  success of the previous intervention (2)
  full-care (FC) a computerized intervention plus
  a fixed number of four 30-min telephone-based
  interventions that equals the maximum of the
  stepped care intervention (3) an untreated
  control group (CG).
• Counseling effort in the intervention conditions
  and quantity/frequency of drinking were assessed
  at 12-month follow-up.
• RESULTS SC participants received roughly half of
  the amount of intervention in minutes compared to
  FC participants. Both groups did not differ in
  drinking outcomes. Compared to CG, intervention
  showed small to medium effect size for at-risk
  drinkers.
• CONCLUSIONS Study results reveal that a stepped
  care approach can be expected to increase
  cost-effectiveness of brief interventions for
  individuals with at-risk drinking.

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• Criteria for appraising the viability,
  effectiveness and appropriateness of a
• screening programme
• Ideally all the following criteria should be met
  before screening for a condition is initiated
• The Condition
• 1. The condition should be an important health
  problem
• 2. The epidemiology and natural history of the
  condition, including development from
• latent to declared disease, should be adequately
  understood and there should be a
• detectable risk factor, disease marker, latent
  period or early symptomatic stage
• 3. All the cost-effective primary prevention
  interventions should have been
• implemented as far as practicable
• The treatment
• There should be an effective treatment or
  intervention for patients identified through
• early detection, with evidence of early treatment
  leading to better outcomes than
• late treatment

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J Gen Intern Med. 2007 Aug22(8)1144-9. Epub
2007 May 31.                 Links Lack of
effect of training on primary care residents'
performance in brief alcohol intervention a
randomized controlled trial. Chossis I, Lane C,
Gache P, Michaud PA, Pécoud A, Rollnick S,
Daeppen JB. Alcohol Treatment Center, Lausanne
University Hospital, Lausanne, Switzerland. BACKGR
OUND Brief alcohol interventions (BAI) reduce
alcohol use and related problems in primary care
patients with hazardous drinking behavior. The
effectiveness of teaching BAI on the performance
of primary care residents has not been fully
evaluated. METHODS A cluster randomized
controlled trial was conducted with 26 primary
care residents who were randomized to either an
8-hour, interactive BAI training workshop
(intervention) or a lipid management workshop
(control). During the 6-month period after
training (i.e., from October 1, 2003 to March 30,
2004), 506 hazardous drinkers were identified in
primary care, 260 of whom were included in the
study. Patients were interviewed immediately and
then 3 months after meeting with each resident to
evaluate their perceptions of the BAI experience
and to document drinking patterns. RESULTS
Patients reported that BAI trained residents
conducted more components of BAI than did
controls (2.4 vs 1.5, p .001) were more likely
to explain safe drinking limits (27 vs 10, p
.001) and provide feedback on patients' alcohol
use (33 vs 21, p .03) and more often sought
patient opinions on drinking limits (19 vs 6, p
.02). No between-group differences were
observed in patient drinking patterns or in use
of 9 of the 12 BAI components. CONCLUSIONS The
BAI-trained residents did not put a majority of
BAI components into practice, thus it is
difficult to evaluate the influence of BAI on the
reduction of alcohol use among hazardous
drinkers.
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Aseltine RH et al The Impact of Screening, Brief
Intervention, and Referral for Treatment on
Emergency Department Patients' Alcohol UseAnnals
of Emergency Medicine. (2007) , 50, 699-710

• 14 sites nationwide
• Patients drinking above low-risk guidelines
• Screened by research staff
• Quasiexperimental control and intervention
  patients were recruited sequentially at each
  site.
• Control a written handout.
• Intervention group received handout and the Brief
  Negotiated Interview (highly structured, on
  laminated pocket sheet) by trained ED staff
  (N402!) , as available
• Follow-up at 3 months by telephone using IVR
  (interactive voice response), or in person IVR

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Aseltine et L, 2007

• Brief Negotiated Interview
• consuming 3.25 fewer drinks per week than
  controls (coefficient B -3.25 95 confidence
  interval CI -5.76 to -0.75),
• Max drinks per occasion three quarters of a
  drink less than controls (B -0.72 95 CI -1.42
  to -0.02).
• At-risk drinkers (CAGE lt2) appeared to benefit
  more from a Brief Negotiated Interview than
  dependent drinkers (CAGE gt2).
• At 3-month follow-up, 37.2 of patients with CAGE
  less than 2 in the intervention group no longer
  exceeded National Institute of Alcohol Abuse and
  Alcoholism low-risk limits compared with 18.6 in
  the control group (? 18.6 95 CI 11.5 to
  25.6).

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Reinhardt et al, Alcohol and Alcoholism 2008, in
press

• 10,803 patients from 85 general practitioners
  were screened using alcohol related
  questionnaires 408 patients were randomised (32
  female) to a control (booklet only) stepped
  care (feedback, manual and up to three
  counselling sessions depending on the success of
  the previous intervention) or fixed care (four
  sessions).
• To include one female patient in the study, 47
  women had to be screened. For one male study
  participant, 17 screenings
• Response rate for the 12 months follow-up was
  91,7
• After excluding dependants and binge drinkers, an
  effect size (R2) of .031 (p.050) in women and
  an effect size (R2) of .069 (p.057) in men

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Training primary care residents' performance in
brief alcohol intervention

• Cluster randomized controlled trial
• 26 primary care residents, randomized to either
  an 8-hour, interactive BAI training workshop
  (intervention) or a lipid management workshop
  (control).
• During the 6-months after training, 506 hazardous
  drinkers were identified
• 260 patients included in the study.
• At 3 months No between-group differences in
  patient drinking patterns or in use of 9 of the
  12 BAI components
• Chossis I, Lane C, Gache P, Michaud PA, Pécoud A,
  Rollnick S, Daeppen JB J Gen Intern Med. 2007
  Aug22(8)1144-9

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• 12-month follow-up assessment

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• J Stud Alcohol Drugs. 2007 Jul68(4)519-28.
  Links
• Alcohol treatment research assessment exposure
  subject reactivity effects part I. Alcohol use
  and related consequences.
• Clifford PR, Maisto SA, Davis CM.
• School of Public Health, University of Medicine
  and Dentistry of New Jersey, 683 Hoes Lane West,
  3rd Floor, Piscataway, New Jersey 08854, USA.
  patrick.clifford_at_umdnj.edu
• OBJECTIVE There has been increasing recognition
  among alcohol treatment researchers that research
  assessment exposure subject reactivity effects
  can contribute to clinical outcomes, decrease
  study design sensitivity, and confound research
  findings. The present study is an experimental
  investigation of two of the more salient
  components of the research assessment interview
  (i.e., frequency and comprehensiveness) and their
  effects on clinical outcomes (Part I Alcohol Use
  and Related Consequences) and treatment
  participation (Part II Treatment Engagement and
  Involvement). METHOD The study design was a 2
  (Frequency of Assessment) x 2 (Comprehensiveness
  of Assessment) completely randomized factorial,
  and study participants were randomly assigned,
  using an urn randomization procedure, to one of
  the resulting four experimental research
  assessment exposure conditions (1)
  frequent-comprehensive, (2) frequent-brief, (3)
  infrequent-comprehensive, and (4)
  infrequent-brief. Study participants were
  recruited from one of two hospital-based
  outpatient alcohol- and other substance-abuse
  clinics. Two hundred thirty-five subjects were
  randomly assigned to one of the four research
  assessment exposure conditions. RESULTS Research
  assessment exposure subject reactivity effects
  were related significantly to alcohol use and
  related negative consequences, such that subjects
  assigned to the infrequent-brief research
  assessment exposure condition reported the
  poorest outcomes. CONCLUSIONS The research
  protocols used to study alcohol treatments have
  clinical efficacy and can alter the outcomes
  (e.g., alcohol use) under investigation. It is
  important for researchers to control/account for
  subject reactivity effects when conducting
  alcohol treatment outcome trials. Accurate
  interpretation of data derived from clinical
  trials of alcohol treatments necessitates taking
  research assessment exposure subject reactivity
  effects into consideration.

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Weekend traffic casualtiesRodriguez-Martos et
al, Alcohol and Alcoholism, 2007, 42430-5

• 2 of 4 hospitals approached agreed to participate
• 79 nurses in Emergency Departments were trained
  (8 trainers), 27 week study.
• 22 of traffic casualties were screened, of whom
  1 in 4 needed advice ( either AUDIT C , or
  DWI). Most (n36,95) got advice.