Tracy Orleans

Behavioral Counseling Interventions in Primary Care To Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force

Alcohol misuse, including risky and harmful drinking, alcohol abuse, and dependence, is associated with numerous health and social problems and with more than 100 000 deaths per year (1). Risky drinkers consume alcohol above recommended daily, weekly, or per-occasion amounts. Harmful drinkers experience harm associated with their alcohol use but do not meet criteria for alcohol abuse or dependence (2). Persons who misuse alcohol have elevated risks for a host of health problems (3-6), including violence-related trauma and injury (4). Most individuals who consume alcohol do so in moderation and without adverse consequences, however, and observational research suggests light or moderate use may be beneficial for some people (7-20). The assumption underlying brief behavioral counseling interventions in primary care is that, for identified risky or harmful drinkers, reducing overall alcohol consumption or adopting safer drinking patterns (that is, fewer drinks per occasion and not drinking before driving) will reduce the risk for medical, social, and psychological problems (21). Little experimental evidence supports this assumption, and most epidemiologic evidence relates health outcomes to existing drinking behaviors rather than to changes in drinking behaviors. Cross-sectional and cohort studies have consistently related high average alcohol consumption to short- or long-term health consequences (4, 22). A meta-analysis of studies examining the association between all-cause mortality and average alcohol consumption found that men averaging at least 4 drinks per day and women averaging 2 or more drinks per day experienced significantly increased mortality relative to nondrinkers (23). Studies also relate heavy per-occasion alcohol use (binge drinking) to acute injury risks and alcohol-related life problems (4, 22). Injury rates are higher for binge drinkers who consume 5 or more drinks on one occasion as infrequently as 3 to 6 times per year, even when average intake is not excessive (24). In the United States, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has proposed epidemiologically based alcohol use guidelines to limit risks for short- and long-term drinking-related consequences by establishing age- and sex-specific recommended consumption thresholds (25). Maximum recommended consumption is 1 or less standard drink per day for adult women and for anyone older than 65 years of age and 2 or fewer standard drinks per day for adult men. These guidelines do not apply to persons (such as adolescents, pregnant women, and persons with alcohol dependence or medical conditions or medication use) for whom alcohol intake is contraindicated, or to circumstances (driving) in which no consumption is considered safe. Primary care clinicians commonly see patients with a range of alcohol-related risks and problems. In Wisconsin, about 20% of primary care patients were found to exceed NIAAA guidelines and to qualify as risky drinkers (26). Across multiple primary care populations, 4% to 29% are risky drinkers, 0.3% to 10% are harmful drinkers, and 2% to 9% exhibit alcohol dependence (27). Prevalence of these forms of alcohol misuse generally is higher in males and younger persons of all races and ethnicities (28). The NIAAA and others encourage physicians to identify patients with alcohol-related risks or problems and to provide office-based brief interventions or referrals as needed (25, 29, 30). In everyday practice, screening and screening-related assessment procedures are necessary to identify the range of alcohol users in order to offer appropriate treatment (31, 32). Even so, few primary care clinicians use recommended screening protocols or offer treatment (33). To assist the U.S. Preventive Services Task Force (USPSTF) in updating its 1996 recommendation (34), the Oregon Evidence-based Practice Center systematically reviewed the evidence on primary carebased behavioral counseling interventions for risky/harmful alcohol use; systematic evidence reviews and meta-analyses since the last USPSTF report (35-39) did not adequately address the key questions posed by the USPSTF. This review was exempted by the Institutional Review Board at Kaiser Permanente Northwest (FWA 00002344-IRB 00000405). Our review addressed the following questions: Do behavioral counseling interventions in primary care reduce risky or harmful alcohol use? What are elements of effective interventions? Do such interventions improve health outcomes? What methods were used to identify risky/harmful drinkers for behavioral counseling interventions in primary care? What adverse effects are associated with interventions addressing risky/harmful drinkers in primary care? What health care system influences are present in effective interventions for risky and harmful drinkers in primary care? Methods We concentrated our review on the program elements of brief primary care interventions for risky and harmful drinkers and their effects on alcohol use, health outcomes, and intermediate alcohol-related outcomes. Appendix Figure 1 shows the analytic framework and key questions guiding the entire systematic evidence review. Methods not described in this section appear in the Appendix, Appendix Figures 2 and 3, and Appendix Table 1. Appendix Figure 1. Analytic framework and key questions ( KQs ). Appendix Figure 2. Literature search and retrieval results. Appendix Figure 3. Risky/harmful alcohol use: quality recheck instrument. Definitions No consistent definitions for the drinking patterns that should be the focus of primary care interventions are available from existing guidelines or research; however, it is commonly held that less severe alcohol problems are appropriate for brief interventions in primary care, whereas more severe problems need specialty addiction treatment (41). We adapted the following definitions from a recent systematic review of primary care screening for alcohol problems (2). Risky or hazardous drinkers are at risk from consumption that exceeds daily, weekly, or per-occasion thresholds (other terms further distinguish risky/harmful users who exceed longer-term thresholdshigh-average or heavy usersfrom heavy occasional or binge drinkers, who exceed per-occasion thresholds). Harmful drinkers experience physical, social, or psychological harm from their above-threshold alcohol use without meeting criteria for dependence. Alcohol-abusing/dependent drinkers continue to use alcohol despite significant negative physical, psychological, and social consequences (42); generally meet criteria for abuse or dependence as outlined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (43); and are candidates for specialty addiction treatment. Our review focuses on studies oriented toward the risky/hazardous/harmful category, which we refer to as risky/harmful drinkers. Fiellin and colleagues (2) similarly divide the literature on screening instruments for alcohol problems into studies that focus primarily on risky, heavy, or harmful drinking and studies that focus on detecting alcohol abuse or dependence. Among the brief intervention studies targeting risky/harmful drinkers selected for this review, we classified intervention groups into 1 of 3 levels of intensity: 1) very brief interventions had 1 session, up to 5 minutes long; 2) brief interventions had 1 session, up to 15 minutes long; and 3) brief multicontact interventions had an initial session up to 15 minutes long, plus follow-up contacts. We used the definition of primary care recommended by the Institute of Medicine (44) (see Inclusion and Exclusion Criteria in the Appendix) to identify relevant medical settings for our review. Inclusion and Exclusion Criteria We included English-language reports of randomized or nonrandomized, controlled clinical trials of nondependent drinkers 12 years of age or older who received a primary care behavioral counseling intervention primarily to reduce alcohol intake. We excluded studies based in hospitals or emergency departments, specialty addiction treatment settings, behavioral health departments, and schools or community agencies without health clinics. We also excluded studies among comorbid patient populations because of limited generalizability to primary care. We excluded studies rated as having poor quality, as described below. Search Strategy We identified 5 recent systematic reviews addressing primary care brief interventions to reduce risky/harmful alcohol use (35-39) and 3 addressing screening (2, 45, 46) from the Cochrane Database of Systematic Reviews and Database of Research Effectiveness (DARE). Relevant trials were identified from searches of MEDLINE, Cochrane Controlled Clinical Trials, PsycINFO, HealthSTAR, and CINAHL databases (1994 to April 2002), reference lists of systematic reviews, the USPSTF 1996 recommendation (34), and experts. We conducted separate searches in MEDLINE and PsycINFO from 1994 through April 2002 to identify any literature on harms related to alcohol screening, screening-related assessment, or intervention. None was found. The Appendix contains further search strategy details, along with information on our abstract and article review processes. We used USPSTF internal validity criteria (40) (Table 1), supplemented by specific quality criteria addressing study randomization, attrition, and intention-to-treat analyses from the Cochrane Drug and Alcohol Group (CDAG) (47) (Appendix Figure 3), to grade the quality of trials that met inclusion and exclusion criteria. We assigned each studys final quality rating according to investigator team consensus. Minimal to no attrition, nondifferential attrition, and replacement of missing values in the outcome analyses were key features of trials rated good quality. Studies receiving a consensus rating of poor quality (n = 27) were excluded from the review (Appendix Table 2). Major quality problems included nonrandom assignment, noncomparable bas