Effectiveness of brief alcohol interventions in primary care populations

Abstract

Background: Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person's alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.This is an update of a Cochrane Review published in 2007.

Objectives: To assess the effectiveness of screening and brief alcohol intervention to reduce excessive alcohol consumption in hazardous or harmful drinkers in general practice or emergency care settings.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and 12 other bibliographic databases to September 2017. We searched Alcohol and Alcohol Problems Science Database (to December 2003, after which the database was discontinued), trials registries, and websites. We carried out handsearching and checked reference lists of included studies and relevant reviews.

Selection criteria: We included randomised controlled trials (RCTs) of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. The comparison group was no or minimal intervention, where a measure of alcohol consumption was reported. 'Brief intervention' was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 minutes. Any more was considered an extended intervention. Digital interventions were not included in this review.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. We carried out subgroup analyses where possible to investigate the impact of factors such as gender, age, setting (general practice versus emergency care), treatment exposure and baseline consumption.

Main results: We included 69 studies that randomised a total of 33,642 participants. Of these, 42 studies were added for this update (24,057 participants). Most interventions were delivered in general practice (38 studies, 55%) or emergency care (27 studies, 39%) settings. Most studies (61 studies, 88%) compared brief intervention to minimal or no intervention. Extended interventions were compared with brief (4 studies, 6%), minimal or no intervention (7 studies, 10%). Few studies targeted particular age groups: adolescents or young adults (6 studies, 9%) and older adults (4 studies, 6%). Mean baseline alcohol consumption was 244 g/week (30.5 standard UK units) among the studies that reported these data. Main sources of bias were attrition and lack of provider or participant blinding. The primary meta-analysis included 34 studies (15,197 participants) and provided moderate-quality evidence that participants who received brief intervention consumed less alcohol than minimal or no intervention participants after one year (mean difference (MD) -20 g/week, 95% confidence interval (CI) -28 to -12). There was substantial heterogeneity among studies (I² = 73%). A subgroup analysis by gender demonstrated that both men and women reduced alcohol consumption after receiving a brief intervention.We found moderate-quality evidence that brief alcohol interventions have little impact on frequency of binges per week (MD -0.08, 95% CI -0.14 to -0.02; 15 studies, 6946 participants); drinking days per week (MD -0.13, 95% CI -0.23 to -0.04; 11 studies, 5469 participants); or drinking intensity (-0.2 g/drinking day, 95% CI -3.1 to 2.7; 10 studies, 3128 participants).We found moderate-quality evidence of little difference in quantity of alcohol consumed when extended and no or minimal interventions were compared (-14 g/week, 95% CI -37 to 9; 6 studies, 1296 participants). There was little difference in binges per week (-0.08, 95% CI -0.28 to 0.12; 2 studies, 456 participants; moderate-quality evidence) or difference in days drinking per week (-0.45, 95% CI -0.81 to -0.09; 2 studies, 319 participants; moderate-quality evidence). Extended versus no or minimal intervention provided little impact on drinking intensity (9 g/drinking day, 95% CI -26 to 9; 1 study, 158 participants; low-quality evidence).Extended intervention had no greater impact than brief intervention on alcohol consumption, although findings were imprecise (MD 2 g/week, 95% CI -42 to 45; 3 studies, 552 participants; low-quality evidence). Numbers of binges were not reported for this comparison, but one trial suggested a possible drop in days drinking per week (-0.5, 95% CI -1.2 to 0.2; 147 participants; low-quality evidence). Results from this trial also suggested very little impact on drinking intensity (-1.7 g/drinking day, 95% CI -18.9 to 15.5; 147 participants; very low-quality evidence).Only five studies reported adverse effects (very low-quality evidence). No participants experienced any adverse effects in two studies; one study reported that the intervention increased binge drinking for women and two studies reported adverse events related to driving outcomes but concluded they were equivalent in both study arms.Sources of funding were reported by 67 studies (87%). With two exceptions, studies were funded by government institutes, research bodies or charitable foundations. One study was partly funded by a pharmaceutical company and a brewers association, another by a company developing diagnostic testing equipment.

Authors' conclusions: We found moderate-quality evidence that brief interventions can reduce alcohol consumption in hazardous and harmful drinkers compared to minimal or no intervention. Longer counselling duration probably has little additional effect. Future studies should focus on identifying the components of interventions which are most closely associated with effectiveness.

Conflict of interest statement

Nicolas Bertholet is salaried by Lausanne University Hospital, a public institution; he has received grants from the Swiss National Science Foundation, the Swiss Foundation for Alcohol Research, and the Department of Community Medicine and Health from the Lausanne University Hospital. He has received no personal support from industry sources such as pharmaceutical, alcohol and tobacco companies and holds no personal stock. Dr Bertholet is an author of a previous systematic review on the subject (Bertholet 2005), and has participated in numerous studies on screening and brief intervention (not limited to the scope of this review), including as a primary investigator of a randomised trial of an electronic screening and brief intervention.

Bernard Burnand, MD, MPH, is Chief Physician at the Institute of Social and Preventive medicine, Lausanne University Hospital. He is salaried full time by the this public institution (Canton of Vaud, Switzerland) and a full professor at the Faculty of Biology and Medicine, University of Lausanne. Bernard Burnand is also Director of Cochrane Switzerland (Cochrane associated centre). His research is supported by Lausanne University Hospital and funding from public granting institutions. ORCID ID: orcid.org/0000‐0002‐5678‐6044

Fiona Campbell has no conflicts of interest to declare.

Jean‐Bernard Daeppen received personal fees from Lundbeck SAS for lectures and advice and was involved in the Daeppen 2007 trial, which is an included trial in this systematic review.

Elizabeth Pienaar is in the full‐time employ of the South African Medical Research Council and has no conflicts of interest to declare.

John B Saunders has no conflicts of interest to declare.

Eileen Kaner, Fiona Beyer and Colin Muirhead are authors on a related Cochrane Review on interventions for reducing hazardous and harmful alcohol consumption (Kaner 2017).

Eileen Kaner is an investigator on the ongoing SIPS Junior trial (NIHR programme grant number NIHR RP‐PG‐0609‐10162). She was also involved in the SIPS trial (Kaner 2013) and the Lock 2006 trial which are included studies in this systematic review.

Figures

1

Study flow diagram.

2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

4

Funnel plot for quantity of drinking at 12 months, with pseudo 95% confidence limits.

5

Meta‐regression of quantity of drinking at 12 months on year of publication of trial.

6

Funnel plot for quantity of drinking at 12 months, adjusted for year of publication, with pseudo 95% confidence limits.

7

Meta‐regression of quantity of drinking at 12 months on baseline consumption.

8

Meta‐regression of quantity of drinking at 12 months on treatment exposure (mean duration of intervention for the participants in the trial), for trials comparing brief intervention with control.

9

Meta‐regression of quantity of drinking at 12 months on effectiveness/efficacy score of trial. Lower scores indicate greater efficacy.

10

Meta‐regression of quantity of drinking at 12 months on treatment exposure (mean duration of counselling for the participants in the trial), for trials comparing brief or extended intervention with control.