J. Myles

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

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

Alcohol Screening and Brief Interventions for Offenders in the Probation Setting (SIPS Trial): a Pragmatic Multicentre Cluster Randomized Controlled Trial

AIM To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in the probation setting. Offender managers were randomized to three interventions, each of which built on the previous one: feedback on screening outcome and a client information leaflet control group, 5 min of structured brief advice and 20 min of brief lifestyle counselling. METHODS A pragmatic multicentre factorial cluster randomized controlled trial. The primary outcome was self-reported hazardous or harmful drinking status measured by Alcohol Use Disorders Identification Test (AUDIT) at 6 months (negative status was a score of <8). Secondary outcomes were AUDIT status at 12 months, experience of alcohol-related problems, health utility, service utilization, readiness to change and reduction in conviction rates. RESULTS Follow-up rates were 68% at 6 months and 60% at 12 months. At both time points, there was no significant advantage of more intensive interventions compared with the control group in terms of AUDIT status. Those in the brief advice and brief lifestyle counselling intervention groups were statistically significantly less likely to reoffend (36 and 38%, respectively) than those in the client information leaflet group (50%) in the year following intervention. CONCLUSION Brief advice or brief lifestyle counselling provided no additional benefit in reducing hazardous or harmful drinking compared with feedback on screening outcome and a client information leaflet. The impact of more intensive brief intervention on reoffending warrants further research.

Buprenorphine/naloxone versus methadone and lofexidine in community stabilisation and detoxification: A randomised controlled trial of low dose short-term opiate-dependent individuals

Buprenorphine/naloxone, methadone and lofexidine are medications with utility in the treatment of opiate withdrawal. We report the first randomised controlled trial to compare the effects of these two medications on withdrawal symptoms and outcome during opiate induction/stabilisation and detoxification. A double-blind randomised controlled trial was conducted in an outpatient satellite clinic of a specialist drug service. Eighty opiate dependent individuals meeting DSM-IV criteria for opiate dependence, using ⩽ ½ g heroin smoked/chased or ¼ g heroin injected or ⩽ 30mg methadone, with ⩽ 3 years of opioid dependency, underwent a short-term opiate treatment programme involving induction/stabilisation on methadone 30mg or buprenorphine/naloxone 4mg/1mg, followed by detoxification (where the methadone group was assisted by lofexidine). The main outcome measures were urine drug screens for opiates and withdrawal and craving questionnaires. There were no overall differences in positive urine drug screens and drop-outs during any phase of the study. During induction/stabilisation, withdrawal symptoms subsided more slowly for buprenorphine/naloxone than for methadone, and craving was significantly higher in the buprenorphine/naloxone group (p<0.05, 95% confidence interval −3.5, −0.38). During detoxification, withdrawal symptoms were significantly greater and the peak of withdrawal was earlier for the methadone/lofexidine group than the buprenorphine/naloxone group (p<0.01, 95% confidence interval 3.0, 8.3). Methadone/lofexidine and buprenorphine/naloxone had comparable outcomes during rapid outpatient stabilisation and detoxification in low dose opiate users.

Challenges and solutions in implementing screening and brief interventions for hazardous alcohol use in accident and emergency departments

The SIPS study is a major UK evaluation of screening and brief intervention strategies for alcohol users in primary care, emergency departments and criminal justice settings. Here we present the results of a pilot study of screening tools and the main study screening results in probation settings. In the pilot study 592 individuals in a variety of settings where approached and 205 consented to take part in the study. The screening tools being evaluated were the modified Single Alcohol Screening Questionnaire and the Fast Alcohol Screening Test. The Gold standard comparison was AUDIT. The mean age in the pilot study was 31 years (SD 9) and the majority were male. The overall prevalence of alcohol use disorders in the population was high at 70% with almost 50% at the dependent end of the spectrum. Those scoring positive on AUDIT had significantly poorer overall health status and were greater users of health and criminal justice services. A ROC analysis of the instruments demonstrated high sensitivity and specificity for both M-SASQ and FAST and ROC analysis indicated a marginal superiority of FAST over M-SASQ (AUC 0.97 vs. 0.92). The main study is a pragmatic factorial randomised controlled trial set in probation services in the UK. The study compares screening tool (FAST vs. M-SASQ) and 3 brief interventions (Patient information leaflet vs. Brief advice vs. Brief Lifestyle Counselling). A total of 976 individuals were approached and 854 were eligible and screened with 573 screening positive. The initial results indicate a high prevalence of alcohol use disorders in this population (68%). The sensitivity of M-SASQ and FAST was high (81% vs. 92%) but FAST appears to be more sensitive than M-SASQ at identifying those with more severe alcohol use disorders with an odds ratio for FAST versus M-SASQ of 2.69 (CI 1.55–4.67) for all alcohol use disorders and 1.58 (CI 1.11–2.24) for harmful alcohol use disorders. FAST appears to be the most efficient screening mechanism in this population but we do not yet know how the screening mechanism interacts with the treatment intervention.

Individual and organizational determinants of alcohol screening and brief intervention implementation in emergency departments (SIPS-ED)

35th Annual Scientific Meeting of the Research Society on Alcoholism, June 23-27. San Francisco, California

Screening and Brief Alcohol Intervention in Routine Primary Care in the UK: SIPS Trial Outcomes at Six Months

To understand the effects of chronic alcohol misuse on synaptic signalling, we compare vulnerable and relatively spared cortical areas in brains taken at autopsy from alcoholics and matched controls. Cases with and without common comorbid diseases add important insights: cirrhosis, for example, has major sequelae for brain function because the failing liver cannot remove a range of toxins, especially ammonia. Male-female comparisons form another dimension, since there are well-known sex differences in susceptibility. We have developed a series of molecular techniques to study transcript and protein expression human autopsy brain, and are exploring interactions with markers brought to light by genetic studies. Using synaptosomal and synaptic membrane preparations from well-characterized cases and controls we can quantify receptor binding as well as the expression of isoform subunit transcripts and proteins. We find, in general, that alcoholics without comorbid disease show more marked differences from controls in GABA receptor parameters, whereas NMDA sites are more prominently affected in cirrhotic alcoholics. However, both genotype and gender can modify these outcomes. For example, the A1 allele in the ANKK1 gene, downstream of DRD2, modulates NMDA subunit expression differentially in males and females. As well as hypothesis-driven approaches we have applied discoverybased techniques and were the first to use microarray analysis with human brain. These approaches provide new, sometimes unexpected, leads. Proteomic studies have portrayed selective post-translational changes in the synaptosomal proteins that suggest that epigenetic processes can alter key components of the synaptic machinery. These alterations will have consequences for the efficacy of trans-synaptic signalling in damaged areas of the brain of the alcoholic.Background: Over the past 25 years, many trials of screening and brief alcohol intervention in primary care have reported positive effects in terms of reducing excessive drinking. However, it is still not clear how applicable this evidence is to routine primary care. In addition, there is a need to identify an efficient screening strategy for busy medical practices. Lastly, the evidence-base in unclear on whether brief structured advice or motivational counselling is the required form of brief intervention to produce positive behaviour change. This SIPS trial is a pragmatic evaluation based in regular primary care practices and involving general practitioners and nurses who deliver screening and brief alcohol intervention during their day-to-day work The aim of the trial is to evaluate the effectiveness and cost-effectiveness of different models of screening to identify excessive drinkers and differing intensities of brief intervention to reduce excessive drinking in routine practice. Method: GPs and nurses from 24 practices in England were recruited. Practices were randomly allocated to one of three brief intervention conditions: a leaflet-only control group (n = 8); five minutes of brief structured advice (n = 8); and twenty minutes of brief lifestyle counselling (n = 8). Practices were additionally randomised to either universal or targeted screening and to use either a modified single item (M-SASQ) or the FAST screening tool. Practices in each of the three intervention conditions were asked to recruit at least 31 hazardous or harmful drinkers who received a short baseline assessment followed by brief intervention. Patients were subsequently followed up at six and twelve months after the intervention. Results: Six month follow-up data will be completed by February 2010. With just one month remaining, the follow-up rate is currently 86% and has included 560 patients. The majority of the follow-up work has been via telephone although postal and email follow-up have also been used. Discussion: The presentation will report not only drinking outcomes following brief intervention but also quality of life measures and health service use data. The findings will answer the key question of whether brief intervention is effective in routine practice and if structured advice is sufficient to change drinking behaviour in non-treatment seeking patients or if motivational counselling is more impactful. Finally the costeffectiveness of these approaches will be outlined.

Alcohol screening and brief intervention in criminal justice settings: prevalence and performance of screening tests

The SIPS study is a major UK evaluation of screening and brief intervention strategies for alcohol users in primary care, emergency departments and criminal justice settings. Here we present the results of a pilot study of screening tools and the main study screening results in probation settings. In the pilot study 592 individuals in a variety of settings where approached and 205 consented to take part in the study. The screening tools being evaluated were the modified Single Alcohol Screening Questionnaire and the Fast Alcohol Screening Test. The Gold standard comparison was AUDIT. The mean age in the pilot study was 31 years (SD 9) and the majority were male. The overall prevalence of alcohol use disorders in the population was high at 70% with almost 50% at the dependent end of the spectrum. Those scoring positive on AUDIT had significantly poorer overall health status and were greater users of health and criminal justice services. A ROC analysis of the instruments demonstrated high sensitivity and specificity for both M-SASQ and FAST and ROC analysis indicated a marginal superiority of FAST over M-SASQ (AUC 0.97 vs. 0.92). The main study is a pragmatic factorial randomised controlled trial set in probation services in the UK. The study compares screening tool (FAST vs. M-SASQ) and 3 brief interventions (Patient information leaflet vs. Brief advice vs. Brief Lifestyle Counselling). A total of 976 individuals were approached and 854 were eligible and screened with 573 screening positive. The initial results indicate a high prevalence of alcohol use disorders in this population (68%). The sensitivity of M-SASQ and FAST was high (81% vs. 92%) but FAST appears to be more sensitive than M-SASQ at identifying those with more severe alcohol use disorders with an odds ratio for FAST versus M-SASQ of 2.69 (CI 1.55–4.67) for all alcohol use disorders and 1.58 (CI 1.11–2.24) for harmful alcohol use disorders. FAST appears to be the most efficient screening mechanism in this population but we do not yet know how the screening mechanism interacts with the treatment intervention.

Screening and brief alcohol intervention in primary health care: extending the existing evidence base via the UK SIPS trial

The SIPS study is a major UK evaluation of screening and brief intervention strategies for alcohol users in primary care, emergency departments and criminal justice settings. Here we present the results of a pilot study of screening tools and the main study screening results in probation settings. In the pilot study 592 individuals in a variety of settings where approached and 205 consented to take part in the study. The screening tools being evaluated were the modified Single Alcohol Screening Questionnaire and the Fast Alcohol Screening Test. The Gold standard comparison was AUDIT. The mean age in the pilot study was 31 years (SD 9) and the majority were male. The overall prevalence of alcohol use disorders in the population was high at 70% with almost 50% at the dependent end of the spectrum. Those scoring positive on AUDIT had significantly poorer overall health status and were greater users of health and criminal justice services. A ROC analysis of the instruments demonstrated high sensitivity and specificity for both M-SASQ and FAST and ROC analysis indicated a marginal superiority of FAST over M-SASQ (AUC 0.97 vs. 0.92). The main study is a pragmatic factorial randomised controlled trial set in probation services in the UK. The study compares screening tool (FAST vs. M-SASQ) and 3 brief interventions (Patient information leaflet vs. Brief advice vs. Brief Lifestyle Counselling). A total of 976 individuals were approached and 854 were eligible and screened with 573 screening positive. The initial results indicate a high prevalence of alcohol use disorders in this population (68%). The sensitivity of M-SASQ and FAST was high (81% vs. 92%) but FAST appears to be more sensitive than M-SASQ at identifying those with more severe alcohol use disorders with an odds ratio for FAST versus M-SASQ of 2.69 (CI 1.55–4.67) for all alcohol use disorders and 1.58 (CI 1.11–2.24) for harmful alcohol use disorders. FAST appears to be the most efficient screening mechanism in this population but we do not yet know how the screening mechanism interacts with the treatment intervention.