Research Activities, October 2012: Comparative Effectiveness: Behavioral counseling is an effective treatment for alcohol misuse

Comparative Effectiveness

Behavioral counseling is an effective treatment for alcohol misuse

Behavioral counseling interventions improved certain behavioral outcomes for adults with risky/hazardous drinking habits (i.e., consumption of alcohol above recommended amounts or at levels that increase the risk for health consequences), according to a new review from the Effective Health Care Program of the Agency for Healthcare Research and Quality (AHRQ). The research review assessed the effectiveness of screening followed by behavioral counseling for alcohol misuse in adolescents and adults in primary care settings. Among adults who received behavioral counseling interventions, alcohol consumption decreased by 3.6 drinks per week (from an average of about 23 drinks to about 19 drinks per week).
For most medical outcomes, such as kidney/liver damage, etc., available evidence either found no difference between interventions and controls or was insufficient to draw conclusions. The best evidence of effectiveness was for 10-15 minute sessions on behavior improvement focusing on how patients use or misuse alcohol.
Alcohol misuse, which includes a range of behaviors from risky/hazardous drinking to alcohol dependence, is associated with numerous health and social problems, more than 85,000 deaths per year in the United States, and an estimated annual cost to society of more than $220 billion.
To access Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse and other materials that explore the effectiveness and risks of treatment options for various conditions, visit AHRQ's Effective Health Care Program Web site: http://www.effectivehealthcare.ahrq.gov.

http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=729

Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse

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Background and Objectives for the Systematic Review

Alcohol misuse, which includes the full spectrum from drinking above recommended limits (i.e., risky/hazardous drinking) to alcohol dependence,^1-3 is associated with numerous health and social problems and more than 85,000 deaths per year in the United States.^4-5 Risky or hazardous drinkers consume alcohol above daily, weekly, or per-occasion amounts.⁵ Harmful use is defined by the ICD-10^6-7 as a pattern of drinking that is already causing damage to health. The damage may be either physical (e.g., liver damage from chronic drinking) or mental (e.g., depressive episodes secondary to drinking).
The Diagnostic and Statistical Manual of Mental Disorders (4th Edition, Text Revision; DSM-IV-TR)⁸ defines alcohol abuse as a maladaptive pattern of use leading to clinically significant impairment or distress that meets at least one of the following criteria: use results in failure to fulfill occupational or social obligations due to drinking; use occurs in physically hazardous situations or leads to recurrent legal problems; or use continues despite persistent social or interpersonal problems.
Alcohol dependence is defined as a maladaptive pattern of use leading to clinically significant impairment or distress that meets at least three of the following criteria: tolerance; withdrawal; a great deal of time spent obtaining alcohol, using it, or recovering from its effects; important activities given up or reduced because of alcohol; drinking more or longer than intended; persistent desire or unsuccessful efforts to cut down or control alcohol use; or use continued despite knowledge of having a psychological problem caused or exacerbated by alcohol. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA),

men may be at risk for alcohol-related problems if their alcohol consumption exceeds 14 standard drinks per week or 4 drinks per day; and
women may be at risk if they have more than 7 standard drinks per week or 3 drinks per occasion.⁹

A standard drink is defined as one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits.^10,11
Hazardous drinking and alcohol-related disorders are a widespread public health problem in the United States. In 2007, the number of alcoholic liver disease-related deaths was 14,406 and the number of alcohol-induced deaths, excluding accidents and homicides, was 23,199.¹² In 2008, 11,773 people were killed in alcohol-impaired-driving crashes.¹³ These fatalities accounted for 32 percent of all motor vehicle traffic fatalities in the United States. Risky or harmful drinking that goes unrecognized can further complicate the assessment and treatment of other medical and psychiatric conditions.¹⁴
Currently, an estimated 50 percent of adults 18 years of age and older are regular drinkers.¹⁵ About 18 percent of adolescent boys and 14 percent of adolescent girls from 12 to 17 years of age reported drinking before age 13.¹⁶ Although often underreported, alcohol use remains common among older people. An estimated 6 percent of older adults are considered to be heavy users of alcohol.¹⁷ Lastly, in a recent survey, 11.8 percent of pregnant women in the United States reported recent use of alcohol.¹⁸
It is generally accepted that less severe alcohol problems (e.g., risky/hazardous drinking) are appropriate for brief interventions in primary care, whereas more severe problems, particularly alcohol abuse and dependence, may require specialty addiction treatment.^1,5,19 However, specialty treatment services may be in short supply, and some people may not be willing to follow up with specialty treatment services. Consequently, primary care physicians may sometimes provide the only care that people with alcohol abuse or dependence receive. Given that alcohol-related problems can cause significant morbidity and mortality, early identification and secondary prevention of alcohol problems by using screening and brief interventions in primary care have been increasingly advocated.^20-22 However, these recent recommendations do not appear to be based on systematic reviews of the evidence, and they lack standardization regarding the practice of brief intervention.
A range of risky drinkers (4–29%) has been found across multiple primary care populations, with prevalence estimates of 0.3 to 10.0 percent for harmful drinkers and 2.0 to 9.0 percent for alcohol dependence.²³ Rates of alcohol-use disorders among medical outpatients are similar to those seen in the general population and are generally higher in males and younger people of all races/ethnicities.^23-24 Physicians who provide ongoing care can assist patients who have current problems, or who are at risk for problems, through effective identification (screening and screening-related assessment), office-based interventions, and referrals to specialty services as needed.²⁵ Patients receiving referrals to specialty care based on positive screening results appear more likely to accept appointments for alcohol-related counseling than those receiving usual care.²⁶
Evidence exists for the effectiveness of screening for early identification of alcohol-related disorders and interventions for alcohol problems in medical settings.²⁷ For example, brief interventions in the primary care setting have shown a net reduction in alcohol consumption of 12 to 34 percent.²⁸ Patients are often more receptive and ready to change than clinicians might expect.²⁰ However, screening and treatment rates remain low. One study of primary care physicians found that although most (88%) reported asking their patients about alcohol use, only 13 percent used standardized screening instruments.²⁹ Another study found that patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10 percent of the time.³⁰ Less than a quarter of people with alcohol-related disorders ever seek help for these conditions; higher proportions of women than men seek help, despite the higher prevalence of alcohol-related disorders in men.¹⁴ Most patients who misuse alcohol receive care from their general practitioner or primary care provider, where they represent about one-fifth of patients seen, a proportion similar to the proportions seen for diabetes and hypertension.¹⁴
In a recent clinician’s guide to the NIAAA guidelines,²⁰ the authors explain that many primary care physicians are familiar with counseling at-risk drinkers but choose to refer most patients to specialized rehabilitation programs. These programs may not be appropriate for problem drinkers who have risky or harmful alcohol use but do not meet the DSM-IV-TR criteria for abuse or dependence. Even if patients accept a referral and complete a rehabilitation program, about one-third will not respond to treatment.³¹
The American Society of Addiction Medicine recommends that the services of primary care physicians and other primary health care providers include, at a minimum, the provision of these four elements of care³²:

Assessment of the nature and extent of alcohol, nicotine, and other drug use by patients, with consistency of data collection and documentation akin to the consistency of assessment and documentation of vital signs.
Routine screening for the presence of alcohol, nicotine, or other drug use problems in patients, as well as screening for risk factors for development of alcohol, nicotine, and other drug dependence.
Appropriate intervention by the primary care provider.
Ongoing general medical care services to persons who manifest alcohol, nicotine, or other drug problems, including dependence.

Commonly used screening tools to identify alcohol misuse include but are not limited to the following:

Alcohol Use Disorders Identification Test (AUDIT) and its abbreviated versions, including the AUDIT-C.
Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire.
Michigan Alcoholism Screening Test (MAST) and its abbreviated and population-specific versions.
Rapid Alcohol Problems Screen (RAPS).
Tolerance, Annoyed, Cut-down, Eye-opener (T-ACE) and Tolerance, Worried, Eye-opener, Amnesia, Kut-down (TWEAK) questionnaires, which are based on the CAGE questionnaire and designed for screening pregnant women.
Versions of the single-question screening recommended by NIAAA, also called the Single Alcohol Screening Question (SASQ).
Alcohol-Related Problems Survey (ARPS), shortened version (shARPS)
The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), which was developed by the World Health Organization.

Behavioral interventions and patient education are often used for patients who have less severe alcohol use (i.e., risky/hazardous/harmful drinking).⁵ Brief interventions generally aim to moderate a patient’s alcohol consumption to sensible levels and to eliminate harmful drinking practices, rather than to insist on complete abstinence. There is ongoing debate about what exactly constitutes a brief intervention.³³ The Substance Abuse and Mental Health Services Administration (SAMHSA) defines brief intervention as “a single session or multiple sessions of motivational discussion focused on increasing insight and awareness regarding substance use and motivation toward behavioral change.”³⁴ The assumption underlying brief interventions is that reducing overall alcohol consumption or improving drinking patterns toward safer use will lower the risk of medical, social, and psychological problems.³⁵ These interventions range from very brief interventions within a primary care visit to multicontact interventions that entail multiple, often more lengthy, visits and nonvisit contacts over an extended period.¹ Brief alcohol interventions can include the following:

Motivational interviews of varying length and number
Cognitive behavioral therapy
Self-completed action plans
Written health education or self-help materials
Requests to keep drinking diaries
Written personalized feedback
Followup telephone counseling
Exercises to complete at home

In 2004, the U.S. Preventive Services Task Force (USPSTF) developed guidelines for screening and behavioral counseling interventions in primary care to reduce risky/harmful alcohol use.¹⁹ The USPSTF makes a distinction between screening and screening-related assessment:

Screening: identifying patients with probable risky/harmful alcohol use.
Screening-related assessment: confirming screening results and distinguishing patients suitable for brief interventions from those needing specialty care referral

In 2004, the USPSTF also recommended the following¹⁹:

Screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. Grade: B Recommendation
Evidence is insufficient to recommend for or against screening and behavioral counseling interventions to prevent or reduce alcohol misuse by adolescents in primary care settings. Grade: I Statement

The original systematic review conducted by the Oregon Evidence-based Practice Center covered the literature through February 2003 and addressed nonpregnant adults, pregnant women, and adolescents in primary care settings. The results of this systematic review, which were published in 2004, were used as the basis for the 2004 USPSTF recommendations discussed above. Several agencies have subsequently published clinical practice guidelines, including the Institute for Clinical Systems Improvement (2009),²² the Michigan Quality Improvement Consortium (2009),²¹ SAMHSA (2009),³⁶ and NIAAA (2005).^9,33 None of the recent guidelines appear to be based on a systematic review of the evidence. Lastly, guidelines approach the subject of brief alcohol interventions differently; there does not appear to be one standardized approach for the practice of brief intervention.
The main objective for this report is to conduct a systematic review of the effectiveness of screening followed by behavioral counseling, with or without referral, for alcohol misuse in primary care settings. We will update the evidence review produced for the USPSTF in 2004 with some revisions and expansions to the scope of the review. This new comparative effectiveness review (CER) adopted nearly all of the Key Questions (KQs) identified in the earlier systematic review, titled Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use.² In addition, a number of important changes are included:

We decided to include the full spectrum of alcohol misuse, expanding the CER to include alcohol abuse and dependence.
We expanded the eligible settings from traditional primary care to also include settings with primary care-like relationships (e.g., infectious disease clinics for people with HIV).
We added additional outcomes of interest to our populations, interventions, comparators, outcomes, timing, and settings (PICOTS) and analytic framework.
We added “referral” as an intervention of interest and changed the title to reflect this addition.