Brief interventions for excessive drinkers in primary care

health settings (Protocol)

Kaner E, Campbell C, Pienaar ED, Heather N, Schlesinger C, Saunders J

This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2003, Issue 2
http://www.thecochranelibrary.com

Brief interventions for excessive drinkers in primary care health settings (Protocol)
Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Brief interventions for excessive drinkers in primary care health settings (Protocol) i
Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Brief interventions for excessive drinkers in primary care

health settings

E Kaner1 , C Campbell, ED Pienaar, N Heather, C Schlesinger, J Saunders

1 Primary Health Care/Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne, UK

Contact address:

Editorial group: Cochrane Drugs and Alcohol Group.

Publication status and date: Unchanged, published in Issue 1, 2005.

Citation: Kaner E, Campbell C, Pienaar ED, Heather N, Schlesinger C, Saunders J. Brief interventions for excessive drinkers in primary
care health settings. The Cochrane Database of Systematic Reviews , Issue . Art. No.: CD004148. DOI: 10.1002/14651858.CD004148.

Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

This is the protocol for a review and there is no abstract. The objectives are as follows:

To determine the effects of brief interventions in reducing excessive alcohol consumption in routine primary health care and characterise
the types of drinkers to whom these effects relate. The following comparisons will be made:

1) Brief intervention vs a control condition (assessment only, standard treatment or non-intervention)

2) Brief intervention vs a extended psychological intervention.

Subgroup analysis will be undertaken to assess the impact of brief interventions in efficacy (ideal world) and effectiveness (real world)
trials using a coding scale developed from the work of Shadish and colleagues (Shadish 2000) and to account for variability in treatment
exposure relating to the frequency, duration and theoretical basis of the brief intervention. Intervention outcomes will also be classified
according to the time at which they were followed-up to ascertain the short, medium and long-term effects. Finally, the applicability
of brief intervention to different sub-groups of drinkers will be described in narrative form.

to reduce consumption levels and thus reduce a primary cause of

BACKGROUND
avoidable ill health (WHO 1993; DoH 1992; Alcohol Concern
Excessive drinking is a significant cause of mortality, morbidity 2000). The impetus for a preventive approach to alcohol problems
and social problems, both in developed and in developing coun- has been reinforced by epidemiological research which shows that,
tries, with a global cost to health above that of tobacco (WHO on a population level, the majority of alcohol-related harm is not
1999). The true impact of alcohol upon the health of individu- due to drinkers with severe alcohol dependence but attributable to
als and the wider community is however difficult to estimate be- a much larger group of excessive or hazardous drinkers whose con-
cause of the many hidden effects resulting from its use, includ- sumption exceeds recommended drinking levels (Anderson 1991)
ing increased levels of violence, accidents and suicide (Anderson and who experience an increased risk of physical, psychological or
1991). The heavy burden that alcohol use places upon the health social harm.
of populations, and its significant economic consequences, has led
to national and international programmes and policies that seek Early identification and secondary prevention of alcohol problems,
Brief interventions for excessive drinkers in primary care health settings (Protocol) 1
Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
using screening and brief interventions in primary care, has in-
creasingly been advocated as the way forward and thus has been the
focus of a great deal of research (Anderson 1996; Wutzke 2002).
Brief intervention is grounded in social-cognitive theory and typ-
ically incorporates some or all of the following elements: feedback
on the person’s alcohol use and any alcohol-related harm; clarifi-
cation as to what constitutes low risk alcohol consumption; infor-
mation on the harms associated with risky alcohol use; benefits of
reducing intake; motivational enhancement; analysis of high risk
situations for drinking and coping strategies; and the development
of a personal plan to reduce consumption. Although the form that
brief intervention takes may vary between studies (Heather 1995),
core features of these brief interventions in primary care are that
they are delivered by generalist health care workers, they target a
population of excessive (or hazardous) drinkers that tends not to
be seeking help for alcohol problems and they aim for reductions
in consumption behaviour and related harm. Brief interventions
in primary care have been evaluated less frequently with depen-
dent drinkers as the target group since such individuals often need
more intensive treatment than is available in routine primary care
and are likely to require a goal of total abstinence.
There are many opportunities for identifying excessive drinking
in primary care since patients are routinely asked about alco-
hol consumption during new patient registrations, general health
checks, specific disease clinics (e.g. hypertension, diabetes) and
other health screening procedures. Thus brief intervention in rou-
tine primary care would typically occur opportunistically, in the
sense that drinking problems would often not be the primary rea-
son for the presentation and patients would not actively be seek-
ing treatment. In addition, the intervention would need to be de-
livered within the limited time-frame of a standard consultation
(typically 5-15 minutes for a GP, up to 30 minutes for a nurse)
or within the parameters of routine practice (e.g. initial screen-
ing plus either referral to a practice colleague or later return for
intervention). However, brief intervention trials have evaluated a
wide range of activity from a single 5-10 minute session of struc-
tured advice delivered by a general medical practitioner or nurse,
through to multiple sessions of motivational interviewing or some
other form of counseling accompanied by repeated follow-up and
delivered by various personnel in primary care. There has also been
variability in other features of the intervention, such as the pop-
ulation of patients treated, the training and support of therapists,
the theoretical basis underlying the intervention and the use of
accompanying written material.
Consequently, although numerous reviews have indicated bene-
ficial outcomes of brief intervention for excessive drinkers (NHS
Brief interventions for excessive drinkers in primary care health settings (Protocol)
Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CRD 1993; Bien 1993; Agosti 1995; Kahan 1995, Wilk 1997;
Poikolainen 1999, Moyer 2002), crucial questions remain con-
cerning its impact in routine practice and its applicability to the
broader patient population. Whilst there appears to be little doubt
that brief intervention with excessive drinkers can be efficacious in
research settings, there is uncertainty about its extrapolation into
the real world of primary care (Holder 1999; Kaner 2001). Much
of the literature consists of efficacy trials i.e. studies carried out in
tightly controlled conditions designed to optimise internal validity
(Flay 1986). However, if health professionals are to be encouraged
to adopt and administer brief interventions in routine practice, it
is necessary to establish a realistic effect size for brief intervention
delivered in clinically relevant contexts. In addition, a number of
subgroups (e.g. young people, the elderly and ethnic minorities)
exist within broad categorisations such as excessive, problematic
or hazardous drinkers and little is known about how these sub-
groups respond to brief intervention in primary care. Differential
loss of subjects from brief intervention trials has led to a call for
caution in generalizing these results to routine practice (Edwards
1997) but little emphasis has been placed on identifying which
patients were not included in the studies at the outset. Thus there
is a clear need to characterise the types of drinkers for whom brief
interventions have a positive impact and any subgroups that have
not been represented in the trials to date.
OBJECTIVES
To determine the effects of brief interventions in reducing exces-
sive alcohol consumption in routine primary health care and char-
acterise the types of drinkers to whom these effects relate. The
following comparisons will be made:
1) Brief intervention vs a control condition (assessment only, stan-
dard treatment or non-intervention)
2) Brief intervention vs a extended psychological intervention.
Subgroup analysis will be undertaken to assess the impact of brief
interventions in efficacy (ideal world) and effectiveness (real world)
trials using a coding scale developed from the work of Shadish and
colleagues (Shadish 2000) and to account for variability in treat-
ment exposure relating to the frequency, duration and theoretical
basis of the brief intervention. Intervention outcomes will also be
classified according to the time at which they were followed-up to
ascertain the short, medium and long-term effects. Finally, the ap-
plicability of brief intervention to different sub-groups of drinkers
will be described in narrative form.
2
 REFERENCES
Additional references
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Copenhagen: WHO Regional Publications, 1996.
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Brief interventions for excessive drinkers in primary care health settings (Protocol)
Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Kahan 1995
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Physician-Based Interventions with Problem Drinkers: A
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effectiveness of brief interventions for unsafe alcohol
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665-675.
∗
Indicates the major publication for the study
3
SOURCES OF SUPPORT

External sources of support

• Department of Health Primary Care Career Scientist Award UK

Internal sources of support

• Small Grant from the University of Newcastle upon Tyne UK

Brief interventions for excessive drinkers in primary care health settings (Protocol) 4
Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.