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. 2009 Oct 26;2009:1017.

Alcohol misuse

Simon Coulton 1
PMCID: PMC2907792  PMID: 21718573

Abstract

Introduction

Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the World Health Organization (WHO) as one of the top five risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption. This review covers interventions in hazardous or harmful, but not dependent, alcohol users.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions in hazardous or harmful drinkers in the primary-care setting? What are the effects of interventions in hazardous or harmful drinkers in the emergency-department setting? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 18 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review, we present information relating to the effectiveness and safety of the following interventions in primary care and in emergency departments: brief intervention (single- or multiple-session); universal screening plus brief interventions; and targeted screening plus brief interventions.

Key Points

Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the WHO as one of the top five risk factors for disease burden.

  • Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption.

This review covers interventions in hazardous or harmful (but not dependent) alcohol users.

  • Hazardous alcohol consumption is defined as a pattern of alcohol consumption that increases the individual's risk of alcohol-related harm, but is not currently causing alcohol-related harm.

  • Harmful alcohol consumption is a pattern of consumption likely to have already led to alcohol-related harm.

Single- or multiple-session brief intervention reduces alcohol consumption over 1 year in hazardous drinkers treated in the primary-care setting, but we don't know how it affects mortality.

Brief intervention (single- or multiple-session) is also effective at reducing alcohol consumption in people treated in the emergency department, although the evidence is not as strong.

Adding universal screening to brief intervention enhances its benefits when given in primary care.

  • We don't know how effectiveuniversal screening in emergency departments is, as we found no data.

  • We don't know whether targeted screening is effective, as we found no data assessing its use in primary or emergency care.

About this condition

Definition

This review covers interventions in hazardous and harmful alcohol users aged 18 years and older being treated in primary care or in emergency departments. In defining hazardous and harmful alcohol consumption, we have used the WHO categorisation of alcohol-use disorders. Dependent drinkers (who have more serious alcohol misuse problems than harmful or hazardous drinkers) are not covered by this review. It is important to note that threshold levels of hazardous and harmful consumption often vary by country and culture. Hazardous alcohol consumption is defined as a pattern of alcohol consumption that increases the individual's risk of alcohol-related harm, but is not currently causing alcohol-related harm. The quantity and frequency of alcohol consumption that constitutes hazardous consumption is usually specified using threshold levels of consumption. In the UK, these levels are specified as: in excess of 14 standard drinks for women and 21 standard drinks for men in any week, where a standard drink constitutes 10 mL by volume or 8 g by weight of pure ethanol. Harmful alcohol consumption is a pattern of consumption likely to have already led to alcohol-related harm. In the ICD-10, alcohol consumption is defined as harmful if: there is clear evidence that alcohol is responsible for physical or psychological harm; the nature of the harm is identifiable; alcohol consumption has persisted for at least 1 month over the previous 12 months; and the individual does not meet the criteria for alcohol dependence. Harmful alcohol consumption is also conceptualised in terms of a pattern of alcohol consumption in excess of specified limits, which currently stands in the UK as 35 standard drinks for women and 50 standard drinks for men in any week. Hazardous and harmful alcohol users are unlikely to seek treatment specifically for alcohol-related problems, but they may come to the attention of health services through opportunistic screening for alcohol use, or, in the case of people with harmful levels of alcohol consumption, because they exhibit alcohol-related harm at presentation. Alcohol-related harm may be acute (such as alcohol-related accidents, alcohol poisoning, or acute pancreatitis), and may also be chronic (such as hypertension, cirrhosis, depression and anxiety, fetal alcohol syndrome, and fetal alcohol effects). Diagnosis: Clinical presentations in primary and emergency care that are associated with excessive alcohol use include hypertension, accidental injury, hand tremors, duodenal ulcers, gastrointestinal bleeding, cognitive impairments, anxiety, and depression. There are several short paper-based screening instruments available for use in primary-care populations. The Alcohol Use Disorder Identification Test (AUDIT) is a 10-item questionnaire that addresses quantity and frequency of alcohol use, alcohol-related problems, and symptoms of mild alcohol dependence. It exhibits high levels of sensitivity (92%) and specificity (94%). A score of 8 or more is indicative of hazardous alcohol use, and a score of 13 or more indicative of harmful alcohol use. Several shortened versions of the AUDIT exist. AUDIT-C incorporates the first three questions of AUDIT, and measures the quantity and frequency of alcohol consumption; it also has acceptable levels of sensitivity and specificity in primary-care populations (sensitivity: 78% for males, 50% for females; specificity: 75% for males, 93% for females). The FAST alcohol screening test is a short AUDIT derivative specifically developed for use in emergency departments. It identifies 90% of the hazardous alcohol users identified by the 10-item AUDIT questionnaire. Other short screening instruments include the Michigan Alcohol Screening Test, CAGE, and the Paddington Alcohol Test (PAT). A number of biological markers of alcohol use can be used in the diagnosis of hazardous or harmful use. These include elevations in mean red blood cell volume (MCV), serum gamma glutamyl transferase (GGT), and carbohydrate deficient transferrin (CDT). While the results of biochemical tests may be useful as motivating factors in addressing an individual's alcohol consumption, they are less sensitive and specific than screening questionnaires in identifying hazardous and harmful alcohol use.

Incidence/ Prevalence

Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked as one of the top five risk factors for disease burden by the WHO. Based on data from 28 countries in Europe between 1992 and 1996, the prevalence of hazardous alcohol consumption was estimated at between 5% and 41% for men, and 1% to 21% for women. Research in England in 2005 estimated that 7.1 million people, or 23% of the adult population (32% of men and 15% of women), could be categorised as hazardous or harmful alcohol users. The prevalence of hazardous and harmful consumption was highest in people aged 16 to 24 years, and while the prevalence has remained relatively stable in the male population, between 1984 and 2006 it had increased by 50% in the female population. In England, 150,000 hospital admissions annually result from acute or chronic alcohol use, and alcohol use is implicated in 33,000 deaths each year.

Aetiology/ Risk factors

The causes of hazardous and harmful alcohol consumption are uncertain and complex. There is some evidence that genetic susceptibility may play a role, particularly in terms of an individual's response to alcohol consumption. Other approaches address issues of psychological predisposition — particularly the roles of learning theories, expectancies, and self-efficacy. Another approach emphasises the role of market forces and social norms in increasing the availability of alcohol and the acceptability of its use within society. Integrated models that address the complex interplay between genetic, physiological, psychological, and social factors are probably the most reliable approach to understanding the aetiology of alcohol-use disorders.

Prognosis

Some hazardous and harmful alcohol users reduce their consumption to "safe" levels without intervention, and others move in and out of different consumption patterns throughout their lives. Approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption. Harmful alcohol consumption is associated with damage to the liver, increased blood pressure, increased risk of haemorrhagic stroke, cardiomyopathy and arrhythmias, cancer of the oesophagus, gastrointestinal bleeding, and pancreatitis. Psychiatric comorbidities include increased risk of depression, anxiety, suicide, and parasuicide. Alcohol use accounts for 1700 accidental deaths a year and, in the elderly, may be associated with an increased risk for falls. Alcohol use also contributes to the early onset of age-related cognitive deficits, dementia, and Parkinson's disease. From a social perspective, increased alcohol use is associated with increased rates of relationship breakdown, domestic violence, child neglect, and negative impact on neonates — for example, fetal alcohol syndrome.

Aims of intervention

To reduce alcohol-related mortality and injury, and reduce alcohol consumption to within acceptable limits (21 units for men; 14 units for women, where 1 unit is the equivalent of 8 mg of ethanol), and to improve quality of life, with minimal adverse effects of treatment.

Outcomes

All-cause mortality, alcohol-related mortality, alcohol-related accidents and injuries, alcohol consumption, alcohol-related problems, risk-taking behaviour, psychological comorbidity, service utilisation (changes in primary-care attendances, employment, criminal justice), adverse effects of treatment.

Methods

Clinical Evidence search and appraisal February 2009. The following databases were used to identify previously published systematic reviews for this systematic review: Medline 1966 to February 2009, Embase 1980 to February 2009, Psychinfo 1985 to February 2009, and The Cochrane Database of Systematic Reviews, Issue 2, 2009. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and NICE. A search was carried out for RCTs published after the search date of the most recent high-quality systematic review(s) identified. The following databases were used to identify RCTs: Medline 2001 to February 2009, Embase 2001 to February 2009, Psychinfo 2001 to February 2009, and The Cochrane Central Register of Controlled Trials, Issue 2, 2009. An additional search of these databases was performed from 1995 to February 2009 for studies performed in emergency-department settings. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language, including open studies, and containing more than 20 individuals. There was no minimum length of follow-up or maximum loss to follow-up required to include studies. In addition, we use a regular surveillance protocol to capture harms alerts from organisations, such as the FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics, such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).

Table.

GRADE evaluation of interventions for alcohol misuse

Important outcomes Alcohol consumption, alcohol-related problems, psychological co-morbidity, alcohol-related injury
Number of studies (participants) Outcome Comparison Type of evidence Quality Consistency Directness Effect size GRADE Comment
What are the effects of interventions in hazardous or harmful drinkers in the primary-care setting?
33 (at least 7221) Alcohol consumption Single-session brief intervention v no brief intervention (usual care) in hazardous drinkers in primary care 4 –2 0 –1 0 Very low Quality points deducted for incomplete reporting of results, and inclusion of multiple-session brief intervention data in single-session intervention analysis. Directness point deducted for single-session minimal intervention data combined with usual-care data
1 (127) Alcohol-related problems Single-session brief intervention v no brief intervention (usual care) in hazardous drinkers in primary care 4 –1 0 0 0 Moderate Quality point deducted for sparse data
1 (127) Psycological co-morbidity Single-session brief intervention v no brief intervention (usual care) in hazardous drinkers in primary care 4 –1 0 0 0 Moderate Quality point deducted for sparse data
14 (2541) Alcohol consumption Multiple-session brief intervention v no brief intervention (usual care) in hazardous drinkers in primary care 4 –1 0 –1 0 Low Quality point deducted for incomplete reporting of results. Directness point deducted for single-session minimal intervention data combined with usual-care data
59 (at least 11243) Alcohol consumption Single- or multiple-session brief intervention v no brief intervention (usual care) v extended intervention in hazardous drinkers in primary care 4 –2 0 –1 0 Very low Quality point deducted for incomplete reporting of results and unclear details of interventions. Directness point deducted for composite outcome measure
8 (2784) Alcohol consumption Adding universal screening to brief intervention v brief intervention alone in primary care 4 –1 0 0 0 Moderate Quality point deducted for incomplete reporting of intervention
What are the effects of interventions in hazardous or harmful drinkers in the emergency-department setting?
14 (at least 1633) Alcohol consumption Single-session brief intervention v usual care in people presenting to emergency departments with injuries related to alcohol consumption 4 –1 –1 –1 0 Very low Quality point deducted for incomplete reporting of results. Consistency point deleted for different results at different time frames. Directness point deducted for indirect comparison
11 (at least 1301) Alcohol- related injuries Single-session brief intervention v usual care in people presenting to emergency departments with injuries related to alcohol consumption 4 –2 0 0 0 Low Quality point deducted for incomplete reporting of results and unclear details of interventions
1 (539) Alcohol- related injuries Multiple-session brief intervention v no brief intervention (usual care) in people presenting to emergency departments with injuries related to alcohol consumption 4 –1 0 0 0 Moderate Quality point deducted for incomplete reporting of results
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Type of evidence: 4 = RCT; 2 = Observational. Consistency: similarity of results across studies Directness: generalisability of population or outcomes Effect size: based on relative risk or odds ratio

Glossary

Low-quality evidence

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Moderate-quality evidence

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Very low-quality evidence

Any estimate of effect is very uncertain.

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

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BMJ Clin Evid. 2009 Oct 26;2009:1017.

Brief intervention (single- or multiple-session) in primary care

Summary

ALCOHOL CONSUMPTION Single-session brief intervention compared with no brief intervention (usual care) in hazardous drinkers in primary care: Single-session brief intervention may be more effective than usual care at decreasing the proportion of hazardous drinkers at 6 to 12 months, and at reducing the proportion of people who are excessive drinkers. We don't know whether brief intervention is more effective than usual care at reducing binge-drinking episodes at 12 months ( very low-quality evidence ). Multiple-session brief intervention versus no multiple-session brief intervention (usual care): Multiple-session brief intervention may be more effective than usual care at decreasing the proportion of hazardous drinkers at 6 to 12 months, but not at 24 months ( low-quality evidence ). Single- or multiple-session brief intervention versus no brief intervention (usual care) or versus extended intervention in hazardous drinkers in primary care: Single- or multiple-session brief intervention may be more effective than usual care or minimal intervention at reducing the proportion of people with hazardous drinking at 6 to 12 months, and may be more effective than control at reducing the proportion of people who are excessive drinkers (very low-quality evidence). ALCOHOL-RELATED PROBLEMS Single-session brief intervention compared with no brief intervention (usual care) in hazardous drinkers in primary care: A single-session nurse-led brief intervention seems no more effective than standard advice at improving alcohol-related problems at 6 and 12 months in people who tested positive in the Alcohol Use Disorder Identification Test (AUDIT) test ( moderate-quality evidence ). PSYCHOLOGICAL CO-MORBIDITY Single-session brief intervention compared with no brief intervention (usual care) in hazardous drinkers in primary care: A single-session nurse-led brief intervention seems no more effective than standard advice at improving psychological co-morbidity at 12 months in people who tested positive in the AUDIT test (moderate-quality evidence). NOTE We found no direct evidence comparing single-session brief intervention with multiple-session brief intervention.

Benefits

Mortality:

We found no systematic review or RCTs assessing the effects of single- or multiple-session brief intervention (BI) on mortality.

Single-session brief intervention versus no brief intervention (usual care) in hazardous drinkers in primary care:

Alcohol consumption:

We found three systematic reviews and three subsequent RCTs (see table 1 ). The first review compared four interventions in hazardous drinkers (consumption of >96 g/week ethanol in women [12 UK standard drinks]; consumption of >132 g/week ethanol in men [16.5 UK standard drinks]) attending primary care: single-session BI; multiple-session BI; single-session minimal interventions; and usual care. The review included some studies with a lower consumption threshold for hazardous consumption than UK guidelines; this reflects international variations in the drinking thresholds for hazardous consumption. The review found that, at follow-up of 6 to 12 months, single-session BI significantly reduced the proportion of hazardous drinkers compared with usual care. Single-session BI involved a session of advice on alcohol consumption, health risks, and strategies to decrease alcohol intake, lasting 10 to 15 minutes, with possible reinforcing visits. Multiple-session BI involved BIs with several reinforcing sessions lasting 10 to 15 minutes. Single-session minimal intervention was one session of 3 to 5 minutes without stressing strategies to decrease alcohol consumption. Usual care involved no specific advice on alcohol consumption except if required by the health problem reported, or if requested by the patient.

Table 1.

Single- or multiple-session brief interventions versus usual care.

Ref Study design Population Outcome Results Comment
Single-session brief intervention versus no brief intervention (usual care) in hazardous drinkers in primary care
Alcohol consumption
SR; search date 2003; 13 RCTs; number of RCTs in meta-analysis not reported 3198 hazardous drinkers (>96 g/week in women [12 UK standard drinks]; >132 g/week ethanol consumption in men [16.5 UK standard drinks]) Decrease in the number of hazardous drinkers at 6–12 months OR 1.6, 95% CI 1.33 to 1.93; absolute numbers not reported BIs applied in primary care: follow-up of 6–12 months with enough data for an intention-to-treat analysis. Single-session BI involved 1 session of advice on alcohol consumption, health risks, and strategies to decrease alcohol intake, lasting 10–15 minutes, with possible reinforcing visits; single-session minimal intervention was 1 session of 3–5 minutes without stressing strategies to decrease alcohol consumption. Usual care involved no specific advice on alcohol consumption except if required by the health problem reported or if requested by the patient. Results for single-session minimal intervention and usual care were combined as the control
SR; search date 2003; 15 RCTs, none of which were included in the first systematic review 2767 people; 996 dependent drinkers, 1771 heavy or abusive drinkers (criteria for dependent, heavy, or abusive not reported) Alcohol consumption at 3–25 months SMD 0.18, 95% CI 0.07 to 0.29; P <0.01; absolute numbers not reported BI of 30 minutes and above delivered according to the principles of motivational interviewing on the basis of Miller & Rollnick's definition. BIs had to be face to face
SR; search date 2001; 5 RCTs in Spanish men; 3 RCTs included in the first systematic review 557 men with alcohol intake over 21 units/week (1 RCT) or over 35 units/week (4 RCTs) Alcohol consumption at 6–12 months SMD –0.46, 95% CI –0.63 to –0.29; P <0.0005; absolute numbers not reported Single- or multiple-session BI (details not reported)
      Number of excessive drinkers (at least 35 units/week) Proportion who were excessive drinkers: 98/236 (41%) with BI v 74/239 (31%) with control; OR 1.55, 95% CI 1.06 to 2.26
RCT 530 people aged 21–70 years; screened and found positive for high-risk drinking (at least 12 drinks containing 12.8 g alcohol each/week for men; at least 9 drinks/week for women); 2% dependent drinkers Reduction in number of weekly drinks from baseline at 12 months Mean: –5.7 with BI v –3.2 with usual care; mean difference –2.6, 95% CI –4.53 to –0.27 Single session of 5–10 minutes' counselling delivered in primary care by specially trained, attending-level physicians (76%), resident physicians (5%), or nurses (19%). BI was undertaken in 530/9772 people in primary care who were screened for hazardous drinking
      Reduction in average number of binge-drinking episodes (>5 drinks for males; >4 drinks for females) a month at 12 months Mean –2.0 with BI v –1.6 with usual care; mean difference –0.4, 95% CI –1.33 to –0.45  
      Proportion of people drinking safely at 12 months (up to 12 drinks containing 12.8 g of alcohol each/week for men, or up to 9 drinks/week for women) 128/235 (54%) with BI v 103/210 (49%) with usual care; OR 1.60, 95% CI 1.00 to 2.54  
      Proportion of people not binge drinking at 12 months 130/235 (55%) with BI v 103/210 (49%) with usual care; OR 1.37, 95% CI 0.86 to 2.12  
RCT 127 people who tested positive in the Alcohol Use Disorders Identification Test (AUDIT). AUDIT involves a series of 10 questions about alcohol use; men scoring at least 8 and women scoring at least 7 were included AUDIT scores at 6 months 8.81 with BI v 10.77 with standard advice; P = 0.42 BI involved a nurse-delivered single-session BI lasting 5–10 minutes, using the “drink less” protocol, involving structured advice on alcohol, including: standard drink units; recommended low-risk consumption levels; benefits of cutting down drinking; tips on helping participants reduce consumption; advice on how to set goals, determine action, and review progress; and a self-help booklet/diary for participants to take away
      AUDIT scores at 12 months 7.50 with BI v 10.60 with standard advice; P = 0.24  
      Alcohol units/week at 6 months 15.80 with BI v 24.96 with standard advice; P = 0.22  
      Alcohol units/week at 12 months 16.08 with BI v 19.60 with standard advice; P = 0.65  
RCT 599 students age 17–29 years presenting to a university primary healthcare service who scored in the hazardous or harmful range of the AUDIT questionnaire Alcohol consumption at 6 and 12 months 6 months: RR 0.77, 95% CI 0.63 to 0.95, P = 0.02; 12 months: 0.77, 95% CI 0.63 to 0.95, P = 0.01 These results may not be generalisable to a wider primary-care population.
Alcohol-related problems
RCT 127 people who tested positive in the AUDIT. AUDIT involves a series of 10 questions about alcohol use; men scoring at least 8 and women scoring at least 7 were included DPI at 12 months. DPI is a 17-item tool designed to assess adverse consequences of drinking in older adults, excessive consumption, dependence symptoms, and escapist drinking 2.05 with BI v 6.05 with standard advice; mean difference –3.99, 95% CI –12.55 to +4.56; P = 0.33 BI involved a nurse-delivered single-session BI lasting 5–10 minutes, using the “drink less” protocol, involving structured advice on alcohol, including: standard drink units; recommended low-risk consumption levels; benefits of cutting down drinking; tips on helping participants reduce consumption; advice on how to set goals, determine action, and review progress; and a self-help booklet/diary for participants to take away
Psychological co-morbidity
RCT 127 people who tested positive in the AUDIT. AUDIT involves a series of 10 questions about alcohol use; men scoring at least 8 and women scoring at least 7 were included SF-12 Mental Health Questionnaire score at 12 months 53.84 with BI v 53.03 with standard advice; P = 0.67 BI involved a nurse-delivered single-session BI lasting 5–10 minutes, using the “drink less” protocol, involving structured advice on alcohol, including: standard drink units; recommended low-risk consumption levels; benefits of cutting down drinking; tips on helping participants reduce consumption; advice on how to set goals, determine action, and review progress; and a self-help booklet/diary for participants to take away
Multiple-session brief intervention versus no brief intervention (usual care) in hazardous drinkers in primary care
Alcohol consumption
SR; search date 2003; 13 RCTs; number of RCTs in meta-analysis not reported 2383 hazardous drinkers (>96 g/week in women, [12 UK standard drinks]; >132 g/week ethanol consumption in men [16.5 UK standard drinks]) Decrease in the number of hazardous drinkers at 6–12 months OR 1.50, 95% CI 1.12 to 1.95; absolute numbers not reported BIs applied in primary care, follow-up of 6–12 months with enough data for an intention-to-treat analysis. Multiple-session BIs were BIs with several reinforcing sessions, lasting 10–15 minutes; single-session minimal intervention was one session of 3–5 minutes without stressing strategies to decrease alcohol consumption. Usual care involved no specific advice on alcohol consumption except if required by the health problem reported or if requested by the patient. Results for single-session minimal intervention and usual care were combined as the control
RCT 158 people who screened positive for problem drinking (>8 drinks [96 g alcohol] a week for women; >11 drinks [132 g alcohol] a week for men) Number of drinks in previous 7 days at 6 months 10.2 with BI v 16.5 with no BI; P <0.01 Physician-delivered BI involving feedback on participant's behaviour, drinking prevalence, reasons for drinking, adverse effects of alcohol, drinking cues, drinking agreement in form of prescription, and drinking diary cards. Two sessions lasting 10–15 minutes, 1 month apart
      Number of drinks in previous 7 days at 12 months 10.1 with BI v 16.6 with no BI; P <0.01  
      Number of drinks in previous 7 days at 24 months 10.5 with BI v 14.7 with no BI; P <0.05  
      Number of heavy-drinking episodes in previous 30 days at 6 months 1.82 with BI v 4.42 with no BI; P <0.05  
      Number of heavy-drinking episodes in previous 30 days at 12 months 1.11 with BI v 5.46 with no BI; P <0.01  
      Number of heavy-drinking episodes in previous 30 days at 24 months 2.05 with BI v 3.94 with no BI; P value not significant  
      Proportion of people drinking excessively in previous 7 days at 6 months 12/87 (15%) with BI v 21/71 (31%) with no BI; P <0.01  
      Proportion of people drinking excessively in previous 7 days at 12 months 12/87 (15%) with BI v 23/71 (34%) with no BI; P <0.01  
      Proportion of people drinking excessively in previous 7 days at 24 months 13/87 (17%) with BI v 19/71 (31%) with no BI; P = 0.10  
RCT 599 students, aged 17–29 years presenting to a university primary healthcare service who scored in the hazardous or harmful range of the AUDIT questionnaire Total alcohol consumption at 6 and 12 months 6 months: RR 0.79, 95% CI 0.64 to 0.97, P = 0.02 12 months: RR 0.87, 95% CI 0.71 to 1.06, P = 0.16 These results may not be generalisable to a wider primary-care population
Single- or multiple-session brief intervention versus no brief intervention (usual care) or versus extended intervention in hazardous drinkers in primary care
Alcohol consumption
SR; search date 2003; 13 RCTs; 12 RCTs meta-analysed 4353 hazardous drinkers (>132 g/week ethanol consumption in men; >96 g/week in women) Decrease in the number of hazardous drinkers at 6–12 months Proportion who stopped hazardous drinking: 987/1985 (50%) with single- (10–15 minute) or multiple-session BI v 790/2061 (38%) with usual care plus minimal intervention; OR 1.55, 95% CI 1.27 to 1.90, NNT 10, 95% CI 7 to 17 BIs applied in primary care, follow-up of 6–12 months with enough data for an intention-to-treat analysis. Single-session BI involved 1 session of advice on alcohol consumption, health risks, and strategies to decrease alcohol intake lasting 10–15 minutes, with possible reinforcing visits; multiple-session BIs were BIs with several reinforcing sessions, lasting 10–15 minutes; single-session minimal intervention was 1 session of 3–5 minutes without stressing strategies to decrease alcohol consumption. Usual care involved no specific advice on alcohol consumption except if required by the health problem reported or if requested by the patient.
      Number of excessive drinkers (at least 35 units a week) at 6–12 months Proportion who were excessive drinkers at 6–12 months: 98/236 (41%) with BI v 74/239 (31%) with control; OR 1.55, 95% CI 1.06 to 2.26  
SR; search date not reported; 34 RCTs; 9 RCTs included in the first SR People defined as alcohol abusers but not alcohol dependent (79% of trials excluded participants with alcohol dependence). Total number of people analysed not reported Reduction in a composite of drinking-related outcomes at 6–12 months in non-treatment seekers (defined as reduction in quantity of alcohol consumption, proportion of people who had stopped drinking, or proportion of people with problems in multiple life areas) SMD 0.24, 95% CI 0.18 to 0.29, P <0.001; absolute numbers not reported Studies of BI providing no more than 4 sessions; however, data from 1 potentially longer study were included (unclear in this study how many sessions were involved). Details of interventions not reported
      Reduction in a composite of drinking-related outcomes at 12 months and above in non-treatment seekers SMD +0.13, 95% CI –0.01 to +0.06; P value and absolute numbers not reported  
      Reduction in alcohol consumption alone at 6–12 months in non-treatment seekers SMD 0.26, 95% CI 0.20 to 0.32, P <0.001; absolute numbers not reported  
      Reduction in alcohol consumption alone at 12 months and above in non-treatment seekers SMD +0.20, 95% CI –0.01 to +0.41; P value and absolute numbers not reported  
      Reduction in a composite of drinking-related outcomes at 6–12 months in treatment seekers SMD +0.025, 95% CI –0.101 to +0.152; P value and absolute numbers not reported  
      Reduction in a composite of drinking-related outcomes at 12 months and above in treatment seekers SMD +0.008, 95% CI –0.118 to +0.134; P value and absolute numbers not reported  
      Reduction in alcohol consumption alone at 6–12 months in treatment seekers SMD +0.004, 95% CI –0.152 to +0.161; P value and absolute numbers not reported  
      Reduction in alcohol consumption alone at 12 months and above in treatment seekers SMD +0.03, 95% CI –0.11 to +0.17; P value and absolute numbers not reported  
  SR; search date 2006; 22 RCTs 7197 people presenting to primary care consuming on average 306 g of ethanol a week [30 UK standard drinks] over 12 months Decrease in alcohol consumption at 12 months. Single- or mulitple-session BI v control: total alcohol consumption: 22 RCTs; mean difference –38.42, 95% CI –54.16 to –22.67, P <0.001; Men: 7 RCTs; mean difference –57.06, 95% CI –88.72 to –25.39, P = 0.00041; Women: 5 RCTs, mean difference: –9.54, 95% CI –48.32 to +29.24; P = 0.63; single- or multiple-session BI v extended intervention: 5 RCTs, mean difference: –27.96, 95% CI –62.19 to +6.26, P = 0.11; binge-drinking episodes: mean difference –0.03, 95% CI –0.06 to 0  
Universal screening plus brief intervention versus brief intervention alone in primary care
Alcohol consumption
SR; search date 2001; 8 RCTs 2784 people who met criteria for excessive drinking (>11–17 drinks/week in 5 RCTs; >22 drinks/week in 1 RCT; >29 drinks/week in 2 RCTs) Proportion of sensible drinkers at 1 or 4 years (drinking below maximum recommended levels; 12–20 drinks/week for men; 9–13 drinks/week for women) 600/1410 (42%) with BI plus screening v 432/1374 (31%) with BI; P <0001; ARR 10.5%, 95% CI 7.1% to 13.9%; NNT 10, 95% CI 7 to 14 BI in primary care (details not reported) which reported at least 1 outcome reflecting a clinically important change in alcohol consumption and reported the number screened to obtain the study sample
Single-session brief intervention versus no brief intervention (usual care) in people presenting to an emergency department with injuries related to alcohol consumption
RCT 762 adults admitted to trauma centre for treatment of an injury who had either: BAC at least 100 mg/dL; SMAST score at least 3 (score range not reported); BAC of 1 to 99 mg/dL and SMAST 1 or 2; BAC 1–99 mg/dL and GGT above normal; or SMAST 1 or 2 and GGT above normal Reduction in weekly alcohol consumption at 12 months Mean –21.8 "standard" drinks with BI (number of units in a "standard" drink not reported) v –6.7 with usual care; P = 0.03 BI involved a single 30-minute session of motivational interviewing by a psychologist plus a handwritten follow-up letter summarising the session 1 month later
RCT 187 injured drivers at motor vehicle accidents with BAC above 10 mg/dL upon hospital admission, not alcohol dependent Reduction in number of standard drinks a month at 12 months with BI v usual care P = 0.02; absolute numbers not reported BI involved a single 20-minute health interview plus 5 minutes of advice on sensible drinking, plus 15–20 minutes of patient-centred counselling on personal problem-solving strategies
      Reduction in number of standard drinks a month at 12 months with BI v simple advice P = 0.03; absolute numbers not reported  
RCT 85 adults with traffic casualties with BAC above 0.02 g/dL Proportion of people reducing their alcohol consumption at 3 months, assessed by AUDIT-C questionnaire (AUDIT-C uses the first 3 questions about alcohol consumption of the 10-item AUDIT scale) 23/30 (85%) with BI v 19/27 (63%) with usual care; P = 0.06 BI involved a single motivational interview, duration not specified
Alcohol-related injuries
RCT 762 adults admitted to trauma centre for treatment of an injury who had either: BAC at least 100 mg/dL; SMAST score at least 3 (score range not reported); BAC of 1–99 mg/dL and SMAST 1 or 2; BAC 1–99 mg/dL and serum GGT above normal; SMAST 1 or 2 and GGT above normal Admission to hospital for new injuries at 1 year HR 0.53, 95% CI 0.26 to 1.07, P = 0.07; absolute numbers presented graphically BI involved a single 30-minute session of motivational interviewing by a psychologist plus a handwritten follow-up letter summarising the session 1 month later
      Admission to hospital for new injuries at 3 years HR 0.52, 95% CI 0.21 to 1.29, absolute numbers presented graphically  
Multiple-session brief intervention versus no brief intervention (usual care) in people presenting to an emergency department with injuries highly correlated with alcohol consumption
Alcohol-related injuries
RCT 539 adults presenting to emergency department with injury not requiring admission to hospital, hazardous or harmful drinkers defined either by alcohol-positive test (BAC over 0.003 mg/dL), or consumed alcohol in the 6 hours prior to the injury, or scored positive for hazardous or harmful in the AUDIT Alcohol-related injuries (IBC-R) at 1 year Reduction of injury: 36% with multiple-session BI v 6% with usual care; P <0.04 BI involved an initial 40- to 60-minute motivational interviewing session plus a booster motivational interviewing session 7–10 days later. The IBC-R is a questionnaire allowing self-report of the number of times each that 18 different types of injury occurred
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AUDIT: Alcohol Use Disorders Identification Test; BAC: blood alcohol concentration; BI: brief intervention; DPI: Drinking Problems Index; GGT: serum gamma glutamyl transpeptidase; IBC-R: Revised Injury Behavior Checklist; SMAST: Shorter Michigan Alcoholism Screening test.

The second review compared BI versus no BI in excessive alcohol consumers (64% of participants classed as hazardous or harmful alcohol users; 36% exhibited symptoms of alcohol dependence) attending primary care. It found that BI significantly reduced alcohol consumption at 3 to 25 months compared with no BI. These significant reductions included a population of dependent alcohol users less likely to respond to BI. The reported reductions in alcohol consumption may underestimate the actual reductions for hazardous and harmful alcohol users. The BI was face to face, sessions lasted at least 30 minutes, and were delivered according to the principles of motivational interviewing on the basis of Miller & Rollnick's definition.

The third review found that BI (primarily single session) delivered in primary care significantly reduced alcohol consumption at 6 to 12 months compared with no BI. It also found that the proportion of excessive drinkers was significantly smaller with BI compared with no BI.

The first subsequent RCT found no significant difference at 12 months between single-session BI and usual care in: the reduction of weekly drinks; the reduction in binge-drinking episodes a month; the proportion of people drinking safely; the proportion of people not binge drinking; or the proportion of people not binge drinking and drinking safely.

The second subsequent RCT found no significant difference between single-session nurse-led BI and standard advice in Alcohol Use Disorder Identification Test (AUDIT) scores or alcohol units a week at 6 and 12 months. However, the RCT lacked power to detect a significant difference between groups.

The third subsequent RCT (599 students who scored in the hazardous or harmful range of the AUDIT questionnaire) compared a single-session, web-based motivational intervention with control (information leaflet). The RCT found significant reductions in total alcohol consumption at 6 and 12 months for the single-session BI compared with control. The web-based BI is a relatively novel approach, and the trial population was students aged 17 to 29 years attending a university primary-care setting. Therefore, the generalisability of these results to a wider primary-care population may be limited.

Alcohol-related problems:

We found one RCT, which found no significant difference in the Drinking Problems Index scores at 6 and 12 months between single-session nurse-led BI and standard advice. However, the RCT lacked power to detect a significant difference between groups.

Psychological co-morbidity:

We found one RCT, which found no significant difference in SF-12 Mental Health Questionnaire scores at 6 and 12 months between single-session nurse-led BI and standard advice. However, the RCT lacked power to detect a significant difference between groups.

Multiple-session brief intervention versus no brief intervention (usual care) in hazardous drinkers in primary care:

Alcohol consumption:

We found one systematic review and two subsequent RCTs (see table 1 ). The review compared four interventions in hazardous drinkers (consumption of >132 g/week ethanol in men; >96 g/week in women): multiple-session BI; single-session BI; single-session minimal intervention; and usual care. The review found that, at 6 to 12 months' follow-up, multiple-session BI significantly reduced the proportion of hazardous drinkers compared with usual care. Multiple-session BI involved BI with several reinforcing sessions lasting 10 to 15 minutes. Single-session BI involved one session of advice on alcohol consumption, health risks, and strategies to decrease alcohol intake, lasting 10 to 15 minutes, with possible reinforcing visits. Single-session minimal intervention was one session of 3 to 5 minutes without stressing strategies to decrease alcohol consumption. Usual care involved no specific advice on alcohol consumption except if required by the health problem reported, or if requested by the patient.

The first subsequent RCT found significantly fewer drinks in the previous 7 days at 3 to 24 months with two BI sessions 1 month apart compared with no BI. The RCT also found that two BI sessions significantly reduced the number of heavy-drinking episodes in the previous 30 days at 3 to 12 months, but found no significant difference at 24 months. The RCT also found that two BI sessions significantly reduced the proportion of people drinking excessively in the previous 7 days at 3 to 12 months, but found no significant difference at 24 months.

The second subsequent RCT (599 students who scored in the hazardous or harmful range of the AUDIT questionnaire) compared a single-session, web-based motivational intervention plus additional interventions 1 and 6 months later versus control (information leaflet). The RCT found a significant reduction in total alcohol consumption at 6 months, but not 12 months, for the multiple-session BI compared with control. However, these results may not be generalisable to a wider primary-care population.

Single- or multiple-session brief intervention versus no brief intervention (usual care) or versus extended intervention in hazardous drinkers in primary care:

Alcohol consumption:

We found three systematic reviews, which combined data for single- and multiple-session BI versus usual care or extended intervention (defined as more than 4 sessions) (see table 1 ). In the first review, analysis of pooled data combining single-session BI plus multiple-session BI found that any type of BI reduced alcohol consumption, and reduced the proportion of hazardous drinkers at 6 to 12 months, compared with minimal interventions or usual care.

The second review assessed results separately for treatment seekers and non-treatment seekers. In non-treatment seekers, the review found that, compared with no BI, single- or multiple-session BI significantly improved both a composite of all drinking-related outcomes and alcohol consumption alone at 6 to 12 months. However, it found no significant difference between groups at 12 months or longer. In treatment seekers, the review found no significant difference between single- or multiple-session BI and extended treatment in a composite of all drinking-related outcomes, and in alcohol consumption alone, at 6 to 12 months or at 12 months or longer. The review included people with "alcohol problems". It did not define the levels of alcohol consumption in the trials it included, but stated that most trials excluded participants with known alcohol dependence.

The third review compared single- or multiple-session BI with control (defined as no intervention or usual care [i.e., GP advice to cut down drinking, leaflet advice, or usual care plus leaflet]) in a primary-care population of people consuming an average of 306 g of ethanol a week [30 UK standard drinks] over 12 months. The analysis did not separate results for single- and multiple-session BI. However, 13 of the 22 RCTs included were single-session BI studies. The review found that, at 12 months, people in the BI group consumed significantly less alcohol a week compared with control. The review performed a subgroup analysis for gender and found that men in the BI group drank significantly less at 12 months compared with control. However, there was no significant difference in the amount of alcohol women consumed between the BI group and control at 12 months. The review found no evidence that single- or multiple-session BI reduced binge-drinking episodes. The review also found no significant difference in the amount of alcohol consumed in 1 week between single- or multiple-session BI and extended interventions.

Single- versus multiple-session brief intervention:

We found no systematic review or RCTs.

Harms

The systematic reviews and RCTs did not assess adverse effects of BIs.

Comment

Clinical guide:

There is strong evidence on the benefits of BIs for hazardous alcohol users compared with minimal or no intervention. There is some lack of clarity regarding what constitutes a BI. Simple BIs are usually delivered by non-specialist healthcare staff, and involve a short session (usually 5 minutes) of structured advice regarding personalised feedback, individual responsibility to change, clear advice, a menu of strategies to change, and emphasis on encouraging the person to have the confidence to change. More-extensive BIs (usually 1 session lasting 20–30 minutes) are usually directed towards more-harmful alcohol consumers. They may take the form of behavioural self-control training or motivational interventions. BIs are more likely to be effective in populations of hazardous consumers identified by opportunistic screening. More-extensive interventions are likely to be beneficial for populations of harmful alcohol consumers or hazardous consumers who do not benefit from initial BIs.

Substantive changes

Single- or multiple-session brief intervention in hazardous or harmful drinkers in primary care One systematic review and one subsequent RCT added comparing single- or multiple-session brief interventions with either control or extended interventions. Categorisation unchanged (Beneficial).

BMJ Clin Evid. 2009 Oct 26;2009:1017.

Universal screening plus brief intervention in primary care

Summary

ALCOHOL CONSUMPTION Adding universal screening to brief intervention compared with brief intervention alone in primary care: Adding universal screening to brief intervention seems more effective at increasing the proportion of people who are drinking below recommended maximum levels at 1 or 4 years ( moderate-quality evidence ).

Benefits

Adding universal screening to brief intervention versus brief intervention alone in primary care:

Alcohol consumption:

We found one systematic review, which found that adding universal screening to brief intervention (BI) in people attending primary care significantly increased the proportion of people rated as sensible drinkers (drinking below recommended maximum levels) at 1 or 4 years compared with BI alone (see table 1 ).

Harms

The review gave no information on adverse effects.

Comment

Clinical guide:

There is some evidence that universal opportunistic screening in addition to BI is likely to be beneficial in identifying, and intervening with, hazardous and harmful alcohol users. More research is needed on effective strategies of implementation for universal screening and delivery of BI in primary care. The majority of hazardous and harmful alcohol consumers are unlikely to seek treatment for their alcohol use, and may not exhibit overt symptoms of alcohol use. There is less evidence of the potential benefits of targeted screening, so more research is needed in this area.

Substantive changes

No new evidence

BMJ Clin Evid. 2009 Oct 26;2009:1017.

Targeted screening plus brief intervention in primary care

Summary

We found no direct information about adding targeted screening to brief intervention in primary care in the treatment of people with hazardous or harmful drinking.

Benefits

We found no systematic review or RCTs.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2009 Oct 26;2009:1017.

Brief intervention (single- or multiple-session) in emergency departments

Summary

ALCOHOL CONSUMPTION Single-session brief intervention compared with usual care in people presenting to emergency departments with injuries related to alcohol consumption: Single-session brief intervention may be effective at reducing alcohol consumption at 6 and 12 months ( very low-quality evidence ). ALCOHOL-RELATED INJURY Single-session brief intervention compared with usual care in people presenting to emergency departments with injuries related to alcohol consumption: Single-session brief intervention may be no more effective at decreasing alcohol-related injury at 1 year, or admission to hospital with new injuries at 1 and 3 years ( low-quality evidence ). Multiple-session brief intervention versus no multiple-session brief intervention (usual care) in people presenting to emergency departments with injuries related to alcohol consumption: Multiple-session brief intervention seems more effective than usual care at reducing the proportion of people with alcohol-related injury at 1 year ( moderate-quality evidence ). NOTE We found no direct evidence comparing single-session brief intervention with multiple-session brief intervention.

Benefits

Single-session brief intervention versus no brief intervention (usual care) in people presenting to emergency departments with injuries related to alcohol consumption:

Alcohol consumption:

We found one systematic review and four subsequent RCTs comparing single-session brief intervention (BI) versus usual care targeted in people with alcohol-related injuries.

The review (search date 2007; 10 RCTs of interventions designed to reduce alcohol problems in people presenting to the emergency department) compared single-session BI with a minimal or standard intervention. The review found no significant difference in either the quantity of alcohol consumed (P = 0.07; no further data reported) or frequency of alcohol consumption (P = 0.83; no further data reported) at 6 to 12 months after intervention between the groups. The first subsequent RCT found that single-session BI significantly decreased alcohol consumption at 12 months compared with usual care. The second subsequent RCT compared single-session counselling, simple advice, and usual care. The RCT found that the reduction in drinks a month was significantly higher with single-session BI compared with simple advice or usual care. The third subsequent RCT found no significant difference between single-session motivational interview and simple advice in the proportion of people reducing their alcohol consumption at 3 months. The fourth subsequent RCT (198 people aged 18 to 24 years; either alcohol positive on admission to hospital or met screening criteria for alcohol problems) compared single-session BI plus two additional booster sessions by telephone at 1 and 3 months with control (defined as a personalised alcohol feedback report followed by 2 booster sessions by telephone at 1 and 3 months). The RCT found that single-session BI plus additional booster sessions significantly decreased alcohol consumption at 12 months compared with baseline, whereas the control decreased alcohol consumption at 12 months compared with baseline (P <0.001). The RCT did not perform any comparisons between the BI plus additional booster sessions and the control group.

Alcohol-related injury:

We found one systematic review and one subsequent RCT. The review (search date 2007; 10 RCTs) found that single-session BI significantly decreased the risk of experiencing an alcohol-related injury at 6 to 12 months after intervention compared with the control (OR 0.59, 95% CI 0.42 to 0.84). The subsequent RCT found no significant difference between single-session BI and usual care in the proportion of people admitted to hospital for new injuries.

Multiple-session brief intervention versus no brief intervention (usual care) in people presenting to emergency departments with injuries related to alcohol consumption:

Alcohol-related injury:

We found one RCT, which found that multiple-session BI significantly reduced drinking-related injuries over 1 year compared with usual care (see table 1 ).

Harms

The RCTs did not assess adverse effects of BI.

Comment

See comment on brief intervention under question on primary care.

Substantive changes

Brief intervention (single- or multiple-session) in emergency departments One systematic review and one subsequent RCT added comparing single-session brief intervention (BI) with control. The review found no significant difference between single-session BI and control in quantity of or frequency of alcohol consumption, but found that single-session BI significantly decreased the number of alcohol-related injuries compared with control at 12 months. The subsequent RCT found that single-session BI reduced alcohol consumption at 12 months compared with baseline. Categorisation unchanged (Likely to be beneficial).

BMJ Clin Evid. 2009 Oct 26;2009:1017.

Universal screening plus brief intervention in emergency departments

Summary

We found no direct information about universal screening plus brief interventions in emergency departments in the treatment of people with hazardous or harmful drinking.

Benefits

We found no systematic review or RCTs.

Harms

We found no RCTs.

Comment

See comment on universal screening under question on primary care.

Substantive changes

No new evidence

BMJ Clin Evid. 2009 Oct 26;2009:1017.

Targeted screening plus brief intervention in emergency departments

Summary

We found no direct information about targeted screening plus brief intervention in emergency departments in the treatment of people with hazardous or harmful drinking.

Benefits

We found no systematic review or RCTs.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

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