Colin Drummond

Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial.

BACKGROUND Alcohol misuse is highly prevalent among people attending emergency departments, but the effect of intervention by staff working in these departments is unclear. We investigated the effect of screening and referral of patients found to be misusing alcohol while attending an emergency department. METHODS We undertook a single-blind pragmatic randomised controlled trial. Patients received either an information leaflet or an information leaflet plus an appointment with an alcohol health worker. Outcome data were collected by patient interview and examination of hospital records at 6 and 12 months. FINDINGS 599 patients were randomised over a 12-month period. At 6 months, those referred to an alcohol health worker were consuming a mean of 59.7 units of alcohol per week compared with 83.1 units in the control group (t -2.4, p=0.02). At 12 months those referred were drinking 57.2 units per week compared with 70.8 in controls (t -1.7, p=0.09). Those referred to the alcohol health worker had a mean of 0.5 fewer visits to the emergency department over the following 12 months (1.2 compared with 1.7, t -2.0, p=0.046). Differences in quality of life were not found. INTERPRETATION Opportunistic identification and referral for alcohol misuse in an emergency department is feasible, associated with lower levels of alcohol consumption over the following 6 months, and reduces reattendance at the department. Short-term reductions in alcohol consumption associated with referral for brief intervention for alcohol misuse benefit patients and reduce demand for accident and emergency department services.

Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations.

Shekhar Saxena and colleagues summarize the recent WHO Mental Health Gap Action Programme (mhGAP) intervention guide that provides evidence-based management recommendations for mental, neurological, and substance use (MNS) disorders.

Promoting innovation and excellence to face the rapid diffusion of Novel Psychoactive Substances in the EU: the outcomes of the ReDNet project

The recent emergence of new psychoactive compounds (novel psychoactive substances (NPS)) has raised prominent challenges in the fields of drug policy, substance use research, public health and service provision. The Recreational Drugs European Network project, funded by the European Commission, was implemented to improve the information stream to young people and professionals about effects/risks of NPS by identifying online products and disseminating relevant information through technological tools.

Alcohol Screening and Brief Intervention for Adolescents: The How, What and Where of Reducing Alcohol Consumption and Related Harm Among Young People

Aim: The aim of the study was to explore the evidence base on alcohol screening and brief intervention for adolescents to determine age appropriate screening tools, effective brief interventions and appropriate locations to undertake these activities. Methods: A review of existing reviews (2003–2013) and a systematic review of recent research not included in earlier reviews. Results: The CRAFFT and AUDIT tools are recommended for identification of ‘at risk’ adolescents. Motivational interventions delivered over one or more sessions and based in health care or educational settings are effective at reducing levels of consumption and alcohol-related harm. Conclusion: Further research to develop age appropriate screening tools needs to be undertaken. Screening and brief intervention activity should be undertaken in settings where young people are likely to present; further assessment at such venues as paediatric emergency departments, sexual health clinics and youth offending teams should be evaluated. The use of electronic (web/smart-phone based) screening and intervention shows promise and should also be the focus of future research.

The Effectiveness of Electronic Screening and Brief Intervention for Reducing Levels of Alcohol Consumption: A Systematic Review and Meta-Analysis

Background Electronic screening and brief intervention (eSBI) has been shown to reduce alcohol consumption, but its effectiveness over time has not been subject to meta-analysis. Objective The current study aims to conduct a systematic review and meta-analysis of the available literature to determine the effectiveness of eSBI over time in nontreatment-seeking hazardous/harmful drinkers. Methods A systematic review and meta-analysis of relevant studies identified through searching the electronic databases PsychINFO, Medline, and EMBASE in May 2013. Two members of the study team independently screened studies for inclusion criteria and extracted data. Studies reporting data that could be transformed into grams of ethanol per week were included in the meta-analysis. The mean difference in grams of ethanol per week between eSBI and control groups was weighted using the random-effects method based on the inverse-variance approach to control for differences in sample size between studies. Results There was a statistically significant mean difference in grams of ethanol consumed per week between those receiving an eSBI versus controls at up to 3 months (mean difference –32.74, 95% CI –56.80 to –8.68, z=2.67, P=.01), 3 to less than 6 months (mean difference –17.33, 95% CI –31.82 to –2.84, z=2.34, P=.02), and from 6 months to less than 12 months follow-up (mean difference –14.91, 95% CI –25.56 to –4.26, z=2.74, P=.01). No statistically significant difference was found at a follow-up period of 12 months or greater (mean difference –7.46, 95% CI –25.34 to 10.43, z=0.82, P=.41). Conclusions A significant reduction in weekly alcohol consumption between intervention and control conditions was demonstrated between 3 months and less than 12 months follow-up indicating eSBI is an effective intervention.

Opportunistic screening for alcohol use disorders in primary care: comparative study

Abstract Objective To evaluate the efficacy and relative costs of different screening methods for the identification of alcohol use disorders in an opportunistic screening programme in primary care in the United Kingdom. Design Comparative study. Setting Six general practices in south Wales. Participants 194 male primary care attendees aged 18 or over who completed an alcohol use disorders identification test (AUDIT) questionnaire. Main outcome measures Scores on alcohol use disorders identification test and measures of γ-glutamyltransferase, aspartate aminotransferase, per cent carbohydrate deficient transferrin, and erythrocyte mean cell volume. Hazardous alcohol consumption, weekly binge consumption, and monthly binge consumption were ascertained using the time line follow back method over the previous 180 days. Alcohol dependence was determined using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Unit costs were established from published resource references and from actual costs of analysing the biochemical tests. Results A significant correlation was observed be alcohol consumption and score on the alcohol use disorders identification test (Pearsons correlation coefficient r = 0.74) and measures of γ-glutamyltransferase (r = 0.20) and per cent carbohydrate deficient transferrin (r = 0.36) but not aspartate aminotransferase (r = 0.08) or erythrocyte mean cell volume (r = 0.02). The alcohol use disorders identification test exhibited significantly higher sensitivity, specificity, and positive predictive value than all of the biochemical markers for hazardous consumption (69%, 98%, and 95%), weekly binge consumption (75%, 90%, and 71%), monthly binge consumption (66%, 97%, and 91%), and alcohol dependence (84%, 83%, and 41%). The questionnaire was also more cost efficient, with a lower cost per true positive for all consumption outcomes. Conclusion The alcohol use disorders identification test questionnaire is an efficient and cost efficient diagnostic tool for routine screening for alcohol use disorders in primary care.

The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial

Background Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial. Methods and Findings Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings. Conclusions SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions. Trial Registration Current Controlled Trials ISRCTN 93681536

Effectiveness and cost-effectiveness of a stepped care intervention for alcohol use disorders in primary care: pilot study

BACKGROUND Screening for alcohol use disorders identifies a wide range of needs, varying from hazardous and harmful drinking to alcohol dependence. Stepped care offers a potentially resource-efficient way of meeting these needs, but requires evaluation in a randomised controlled trial. AIMS To evaluate the feasibility, effectiveness and cost-effectiveness of opportunistic screening and a stepped care intervention in primary care. METHOD A total of 1794 male primary care attendees at six practices in South Wales were screened using the Alcohol Use Disorders Identification Test (AUDIT). Of these, 112 participants who scored 8 or more on the AUDIT and who consented to enter the study were randomised to receive either 5 minutes of minimal intervention delivered by a practice nurse (control group) or stepped care intervention consisting of three successive steps (intervention group): a single session of behaviour change counselling delivered by a practice nurse; four 50-minute sessions of motivational enhancement therapy delivered by a trained alcohol counsellor; and referral to a community alcohol treatment agency. RESULTS Both groups reduced alcohol consumption 6 months after randomisation with a greater, although not significant, improvement for the stepped care intervention. Motivation to change was greater following the stepped care intervention. The stepped care intervention resulted in greater cost savings compared with the minimal intervention. CONCLUSIONS Stepped care was feasible to implement in the primary care setting and resulted in greater cost savings compared with minimal intervention.

Cannabis control: costs outweigh the benefits. For.

Alex Wodak and colleagues argue that the costs—to health, and fiscal and social—of controlling cannabis are greater than any benefits. In opposition, Colin Drummond lists the potential dangers of decriminalisation. # For {#article-title-2} Current debates on cannabis policy are dominated by attempts to establish the potential health costs of use of cannabis.1 While accurate assessment of the potential harms of cannabis is desirable, it is at least as important to estimate the costs—which are usually ignored—of current cannabis controls. Perhaps doctors have often led the search for less harmful drug policies because the premier axiom of medicine is “first, do no harm.” In 1893 Britains Indian Hemp Drugs Commission concluded that excessive use of cannabis was uncommon and that moderate use produced practically no ill effects. In 1926, Sir Humphrey Rolleston, then president of the Royal College of Physicians, chaired a committee that recommended against criminalising opiates.2 Similarly, Dr W C Woodward, counsel to the American Medical Association, testified in Congress in 1937 to the lack of evidence justifying criminalisation of cannabis3 and several other commissions in Britain, Canada, and the United States have come to similar conclusions.4 In 1972, an American presidential commission concluded that marijuana “does not warrant” the harmful consequences of “criminal stigma and threat of incarceration.”5 In 1978, President Carter told Congress that “penalties against the use of a drug should not be more damaging to an individual than the use of a drug itself; and where they are they should be changed. Nowhere is this more clear than in the laws against the possession of marijuana.”6 Unfortunately, little has changed since President Carter uttered these words. The UK Police Foundations review of cannabis policy in 2000 was the most recent senior international committee to reach the same verdict: “Our conclusion is that …

Screening and brief interventions for hazardous alcohol use in accident and emergency departments: A randomised controlled trial protocol

BackgroundThere is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments.Methods/designThe study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation.DiscussionThis paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments.Trial RegistrationISRCTN 93681536