Mauri Aalto

Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. A systematic review.

Objective. To review systematically the available literature on implementation of brief alcohol interventions in primary healthcare in order to determine the effectiveness of the implementation efforts by the health are providers. Key question. To what extent have the efforts to implement brief alcohol interventions in primary healthcare environments been successful? Method. Literature search from Medline, Cinahl, PsychLIT, Cochrane. Setting. Primary healthcare. Material. A total of 11 studies encompassing 921 GPs, 266 nurses, 88 medical students, and 44 “non-physicians” from Europe, the USA, and Australia. Main outcome measures. Material utilization, screening, and brief intervention rates. Answer. Intervention effectiveness (material utilization, screening, and brief intervention rates) generally increased with the intensity of the intervention effort, i.e. the amount of training and/or support provided. Nevertheless, the overall effectiveness was rather modest. However, the studies examined were too heterogeneous, not scientifically rigorous enough, and applied too brief follow-up times to provide conclusive answers.

AUDIT and its abbreviated versions in detecting heavy and binge drinking in a general population survey

BACKGROUND The aim of this study was to define optimal cut points for the Alcohol Use Disorders Identification Test (AUDIT) and its abbreviated versions (AUDIT-C, AUDIT-QF, and AUDIT-3), and to evaluate how effectively these questionnaires detect heavy drinking in the general population. METHODS The study population consisted of a sub-sample of the National FINRISK Study. A stratified random sample of 3216 Finns, aged 25-64, was invited to a health check. Of these, 1851 (57.6%) completed the AUDIT and participated in person in the Timeline Followback (TLFB) interview regarding their alcohol consumption. The TLFB-based definition of heavy drinking was used as a primary gold standard (for males > or =16 standard drinks average in a week or > or =7 drinks at least once a month; for females, respectively, > or =10 and > or =5 drinks). Areas under receiving operating characteristics curves (AUROCs), sensitivities and specificities were used to compare the performance of the tests. RESULTS AND CONCLUSIONS The AUDIT and its abbreviated versions are valid for detecting heavy drinking also in a general population sample. However, performance seems to vary between the different versions and accuracy of each test is achieved only by using tailored cut points according to gender. The AUDIT and AUDIT-C are effective for both males and females. The optimal cut points for males were found to be >/=7 or 8 for AUDIT and > or =6 for AUDIT-C. Among females the optimal cut points were found to be > or =5 for AUDIT and > or =4 for AUDIT-C. The study also indicates that AUDIT-QF among females and AUDIT-3 among males are relatively effective. The cut points for detecting all heavy drinkers (including binge drinkers without exceeding weekly thresholds) were lower than for detecting heavy drinkers excluding those who are only binge drinkers.

Hazardous Drinking: Prevalence and Associations in the Finnish General Population

BACKGROUND Hazardous drinking, defined as consuming alcohol on a risky level and not meeting the diagnostic criteria of alcohol use disorders (AUDs), has been suggested for a new complementary nondependence diagnosis. This study aimed to investigate the prevalence and associations of hazardous drinking in comparison to AUDs, moderate drinking, and abstinence. METHODS A national representative sample of Finns was examined in the Health 2000 Survey. For 4477 subjects aged 30 to 64 years (76%, 2341 females), both the quantity frequency data about alcohol consumption and Composite International Diagnostic Interview (CIDI) data concerning AUD diagnoses were available. The nationally recommended limits for hazardous dinking were used (males: 24 drinks, females: 16 drinks/wk). Logistic regression models were used to analyze associations. RESULTS The prevalence of hazardous drinking was 5.8%. Hazardous drinking was more prevalent among males than females (8.5% vs. 3.1%). It was most prevalent among the subjects aged 40 to 49 years (7.3%), divorced or separated (8.3%), unemployed (8.2%) and subjects living in the southern (Helsinki) region (7.5%). AUDs versus hazardous drinking were more likely to be in males versus females and in the unemployed versus employed. Subjects aged 40 and over had higher odds for hazardous drinking versus AUDs. The odds for hazardous versus moderate drinking were higher for males versus females (adjusted odds ratio = 3.24), for subjects aged over 40 years, unemployed versus employed and cohabiting, divorced/separated or unmarried subjects versus married subjects. CONCLUSION The high prevalence of hazardous drinking makes it an important public health concern. Hazardous drinkers have different sociodemographic characteristics as compared to people in other alcohol use categories.

The alcohol use disorders identification test (AUDIT) and its derivatives in screening for heavy drinking among the elderly

The performance of the Alcohol Use Disorders Identification Test (AUDIT) in screening for heavy drinking among the elderly has been unsatisfactory. The aim of the present study was to determine whether tailoring the cut point improves the performance of the AUDIT and its derivatives in this age group.

Binge drinking and its detection among middle-aged men using AUDIT, AUDIT-C and AUDIT-3

Binge (heavy episodic) drinking is common, but there is little knowledge on how this drinking pattern could be detected. This study compares three structured questionnaires among binge drinking middle-aged men. All 45-year-old men in the city of Tampere, Finland, were asked to fill in the Alcohol Use Disorders Identification Test (AUDIT). Based on the interview on their drinking the men were divided into non-binging moderate drinkers (n = 352), binging moderate drinkers (n = 130), non-binging heavy drinkers (n = 10) and binging heavy drinkers (n = 63). The complete AUDIT, AUDIT-C (first three AUDIT questions inquiring quantity-frequency) and AUDIT-3 (the third binging-frequency question of AUDIT) in detecting binge drinking were compared. The complete AUDIT was effective in detecting binge drinkers by a cut-off score of >or=8 or >or=7. The optimal cut-off score for AUDIT-C was >or= 6 and that for AUDIT-3 >or=2. The area under the curve (AUC) among all risky drinkers (binging moderate and binging heavy and non-binging heavy drinkers) for AUDIT was 0.824 (95% CI 0.789 - 0.859), for AUDIT-C 0.829 (95% CI 0.795 - 0.864) and for AUDIT-3 0.779 (0.739 - 0.818). The complete AUDIT and its short versions are applicable in populations where binging is the dominant drinking pattern, but the cut-off scores should be tailored to individual cultures.

Alcohol consumption and all-cause mortality among elderly in Finland

AIMS To estimate the gender-specific prevalences of alcohol consumption levels and to investigate the association between heavy drinking and all-cause mortality among elderly males. DESIGN A cohort derived from a nationally representative sample of Finns aged >65 years was followed for six years. Number of subjects was 1569 (72.7% of the original sample, 65.3% females, weighted n=1357). MEASUREMENTS Alcohol consumption was retrospectively measured by beverage-specific quantity and frequency over a 12-month period. Mortality data were obtained from the official Cause-of-Death Register. Cox proportional hazards models were used to analyse the relative risks (RRs) of death. FINDINGS The prevalence of heavy drinking (>8 standard drinks per week) was 20.3% in males and 1.2% in females. Over one-tenth (11.4%) of males reported drinking > or =15 standard drinks per week. Relative death risks suggested a J-curved relationship between alcohol consumption levels and mortality. However, significant curvilinear relationship was not found, when using alcohol consumption as continuous variable. The multivariate adjusted RR of death among moderate drinkers (1-7 drinks per week) vs. abstinent subjects was 0.41 (95% CI=.23-.72). Males drinking > or =15 standard drinks per week had a two-fold multivariate adjusted risk of death (RR=2.11, 95% CI=1.19-3.75) compared with abstinent males. The level of alcohol consumption by females was too low for analysis. CONCLUSIONS Heavy drinking is common among Finnish elderly males but not among females. The present study shows an increased all-cause mortality risk for males drinking, on average, more than two standard drinks per day.

AUDIT-C, AUDIT-3 and AUDIT-QF in screening risky drinking among Finnish occupational health-care patients

INTRODUCTION AND AIMS Primary care physicians need a brief screening instrument to detect risky drinkers. In previous studies, the three first questions of the Alcohol Use Disorders Identification Test-C (AUDIT-C) and the third question on heavy episodic drinking alone (AUDIT-3) have been shown to be almost as effective as the whole AUDIT. Also, AUDIT-QF (the first two questions of AUDIT) can be a potential screening instrument. However, the validity of these short questionnaires has not been studied among the occupational health-care patients. DESIGN AND METHODS Patients visiting their doctor in six occupational health clinics were asked to fill in a health questionnaire containing AUDIT. All together 759 patients participated in the study. Risky drinking was defined as having scored of≥10 for men or≥8 or more for women in the AUDIT questionnaire. Validity of AUDIT-C, AUDIT-3 and AUDIT-QF were compared against the whole AUDIT. RESULTS Based on the whole AUDIT, 92 (24%) of the men and 33 (9%) of the women were risky drinkers. For men and women, area under the curve was relatively high for all tested questionnaires. For AUDIT-C, the best combination of sensitivity and specificity was yielded at cut-off point of 6 for men and 4 for women. DISCUSSION AND CONCLUSION Short questionnaires perform almost as well as the whole AUDIT screening risky drinking among men and women. This is why they can be recommended for clinical use in busy settings. The cut-off points, however, have to be tailored for gender and culture.

Health-related quality of life in alcohol dependence: A systematic literature review with a specific focus on the role of depression and other psychopathology

Abstract Background: Health-related quality of life (HRQOL) is considered a valid measure of treatment effectiveness in addictions. However, alcohol research has lagged behind other biomedical fields in using HRQOL outcomes as primary or secondary endpoints. Previous work has suggested that psychiatric co-morbidity may mediate the relationship between alcohol dependence and HRQOL. Aim: The goal was to summarize the literature on HRQOL and its domains in the context of alcohol dependence. A specific focus was on the impact of depression and other psychopathology on these areas of life. Materials and methods: A database search of MEDLINE and PsychINFO was performed within the scope of PARADISE (Psychosocial fActors Relevant to brAin DISorders in Europe); a European Commission funded coordination action. Using pre-defined eligibility criteria, 42 studies were identified. A systematic approach to data collection was employed. Results and conclusions: Alcohol dependence was shown to affect overall HRQOL and its domains, including general health, physical and mental health, general and social functioning, activities of daily living, pain and sleep. The evidence demonstrating that alcohol dependence is a primary cause of impairments in overall HRQOL, general health, mental and physical health and social functioning was fairly strong. Treatment interventions helped improve HRQOL and its aforementioned domains. The reduction or cessation of alcohol use facilitated these improvements; however, it was not reported to be predictive of improvement in all instances where improvement was reported. Depression was associated with further decreases in HRQOL. Personality disorders contributed to the severity of social functioning impairment.

A brief intervention for risky drinking--analysis of videotaped consultations in primary health care.

In order to study activity in conducting brief alcohol intervention, a total of 83 consecutive consultations by eight general practitioners were videotaped. The categorization included the nature of the patients health problems and whether alcohol consumption was elicited. The discussions were compared to previously given instructions. Alcohol consumption was elicited in 9/34 of the consultations where enquiry was indicated by the instructions, and rarely in any other situations. The activity among the individual physicians varied, but none of them elicited systematically in all situations with indication. No information was given to any of these patients concerning the relation between their symptoms and alcohol consumption. In conclusion, enquiring and advising on alcohol were seldom performed. More training is needed, especially on how to inform individual patients of the health risks of alcohol.

µ-Opioid Receptor Gene (OPRM1) Polymorphism A118G: Lack of Association in Finnish Populations with Alcohol Dependence or Alcohol Consumption

Aims: The molecular epidemiological studies on the association of the opioid receptor µ-1 (OPRM1) polymorphism A118G (Asn40Asp, rs1799971) and alcohol use disorders have given conflicting results. The aim of this study was to test the possible association of A118G polymorphism and alcohol use disorders and alcohol consumption in three large cohort-based study samples. Methods: The association between the OPRM1 A118G (Asn40Asp, rs1799971) polymorphism and alcohol use disorders and alcohol consumption was analyzed using three different population-based samples: (a) a Finnish cohort study, Health 2000, with 503 participants having a DSM-IV diagnosis for alcohol dependence and/or alcohol abuse and 506 age- and sex-matched controls; (b) a Finnish cohort study, FINRISK (n = 2360) and (c) the Helsinki Birth Cohort Study (n = 1384). The latter two populations lacked diagnosis-based phenotypes, but included detailed information on alcohol consumption. Results: We found no statistically significant differences in genotypic or allelic distribution between controls and subjects with alcohol dependence or abuse diagnoses. Likewise no significant effects were observed between the A118G genotype and alcohol consumption. Conclusion: These results suggest that A118G (Asn40Asp) polymorphism may not have a major effect on the development of alcohol use disorders at least in the Finnish population.