Screening and brief intervention for excessive drinking: lessons from research in the primary health

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Screening and brief intervention for excessive
drinking lessons from research in the primary
health care setting

• Nick Heather PhD,
• Centre for Alcohol Drug Studies,
• Newcastle, North Tyneside Northumberland Mental
  Health
• NHS Trust,
• University of Northumbria at Newcastle

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Two disadvantages in addressing the topic of this
conference

• Most of my research on brief alcohol
  interventions has been in the primary care, not
  the hospital setting
• I work in England

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MAIN POINTS OF PRESENTATION

• Opportunistic brief interventions are an
  effective means of helping excessive drinkers
  reduce consumption
• If widely implemented, they would make a
  significant contribution to patient welfare and
  to public health
• Difficulties have been encountered in persuading
  medical and other professionals to implement
  brief interventions
• Nurses have a crucial role to play in this
  implementation process and this provides an
  important opportunity to develop the nurses role
  in health behaviour change

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LATEST EVIDENCE ON EFFECTIVENESS OF BRIEF
INTERVENTIONS

• Moyer, A., Finney, J.W., Swearingen, C.E.
  Vergun, P. (2001). Brief interventions for
  alcohol problems a meta-analytic review of
  controlled investigations in treatment-seeking
  and non-treatment-seeking populations. Addiction,
  97, 279-292.
• Distinction made between opportunistic brief
  interventions and brief treatment
• In the former group of investigations (n34),
  small to medium aggregate effect sizes in favour
  of brief interventions at different follow-up
  points
• At follow-up after 3 to 6 months, the effect for
  brief interventions compared with control
  conditions was significantly larger when
  individuals with more severe alcohol problems
  were excluded

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AREAS OF UNCERTAINTY REGARDING SBI IN PRIMARY
HEALTH CARE

• Longer-term effects
• Evidence of economic benefits
• Clarification of effects among women
• Effects among younger and older excessive
  drinkers
• Evidence of effectiveness when delivered by
  nurses
• Findings from effectiveness rather than
  efficacy studies
• What types and durations of intervention are
  maximally effective for different types of
  drinker?
• Ways to encourage implementation in routine
  practice

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LONGER-TERM EFFECTS

• Data on longer-term effects from 3 studies
• Kristenson et al. (1983) 5-6 years/ Sweden
• Fleming et al. (2001) 4 years/ USA
• Wutzke et al. (2002) 10 years/ Australia
• Some evidence for continuing medium-term benefits
  (4-6 years)

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EVIDENCE OF ECONOMIC BENEFITS

• Some earlier studies provided data relevant to
  economic evaluation but until recently no formal
  and full economic evaluations had been carried
  out
• Fleming et al. (2000) reported a benefit-cost
  ration of 5.61 or 56,263 in total benefit for
  every 10,000 invested
• Fleming et al. (2001) - at 4 years after
  intervention, 43,000 reduction in future health
  care costs even larger benefits to society in
  terms of fewer motor vehicle accidents and
  life-years lost
• Wutzke et al. (2001) calculated that, if an SBI
  programme were implemented in primary health care
  throughout Australia, the marginal costs per
  additional life year saved would be below
  Aus1,873

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CLARIFICATION OF EFFECTS AMONG WOMEN

• The WHO Phase II study (Babor Grant, 1992)
  reported an effect of intervention among men but
  not among women. Same for Anderson Scott
  (1990/92) study in Oxford
• In these studies, female patients decreased
  average consumption in both intervention and
  control groups. How can this be explained? Effect
  of assessment?
• Fleming et al. (1996) showed that, when
  assessment masked from patients, women show a
  larger response than men

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EFFECTS AMONG YOUNGER EXCESSIVE DRINKERS

• There are now several studies of brief
  intervention among young heavy drinkers but these
  are mostly in AE settings
• There is also evidence for effectiveness in
  educational establishments, so school and
  university medical services could be used to
  deliver brief interventions
• The potential of regular primary health care
  services for this purpose remains to be explored
  (e.g. sexual health clinics as a way of
  identifying and intervening among young female
  heavy drinkers)

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EFFECTS AMONG OLDER EXCESSIVE DRINKERS

• Fleming et al. (1999) reported trial of brief
  physician advise in older adults (65)
• Compared with controls, patients in intervention
  group showed
• 34 reduction in 7-day alcohol use
• 74 reduction in mean number of binge-drinking
  sessions
• 62 reduction in the drinking more than
  21drinks/week

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EVIDENCE OF EFFECTIVENESS WHEN DELIVERED BY NURSES

• Several well-known studies have included nurses
  as providers of brief interventions (e.g.,
  Kristenson et al., Israel et al., WHO Phase II
  study)
• But until now there has been no RCT specific to
  nurse-delivered brief intervention
• RCT in Newcastle upon Tyne nearing completion

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FINDINGS FROM EFFECTIVENESS STUDIES RATHER THAN
EFFICACY STUDIES

• Most trials of SBI are efficacy studies
• When effectiveness studies have been carried out,
  effect of intervention is less
• Effectiveness studies should be based on
  customising SBI to the characteristics of the
  primary health care systems of individual
  countries, as in WHO Phase IV
• But we need more effectiveness trials

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WHAT TYPES AND DURATIONS OF INTERVENTION ARE
MAXIMALLY EFFECTIVE FOR DIFFERENT TYPES OF
DRINKER?

• Some evidence for greater effectiveness of
  motivational approach than skills-based approach
  among those not ready to change but more work
  needed on this and other possible matches
• Some studies have found no added advantage of
  relatively more intensive intervention cf.
  minimal intervention but others have
• This inconsistency needs to be clarified,
  possibly by demonstration of patient-intervention
  matches

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TYPES OF BRIEF INTERVENTION(1) Brief structured
advice

• 5-10 minutes
• preferably personalised (i.e., based on
  assessment)
• consistent with FRAMES (Feedback, Responsibility,
  Advice, Menu, Empathy, Self-efficacy)
• accompanied by self-help materials (written,
  audio-tape, video-tape, computer interactive)
• delivered by doctor or nurse

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TYPES OF BRIEF INTERVENTION(2) Condensed
cognitive-behavioural therapy

• 30-40 minutes, one or more sessions
• also called Skills-based Training or
  Self-management Training
• special training (i.e., of interventionist)
  required
• especially appropriate for patients ready to
  change or, at least, preparing to change
• best delivered by nurse

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TYPES OF BRIEF INTERVENTION(3) Brief
motivational interviewing

• 40-60 minutes, one or more sessions
• special training required
• especially appropriate for patients not ready to
  change
• best delivered by nurse

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WAYS TO ENCOURAGE IMPLEMENTATION IN ROUTINE
PRACTICE

• This is the most crucial area of uncertainty -
  the best way to persuade primary health care
  professionals to incorporate SBI in routine
  practice
• Results from around the world so far
  disappointing
• To find a solution to this problem in each
  participating country is precisely the aim of the
  WHO Phase IV project

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Three key concepts for implementation of SBI
(from Maudsley study, 1975)

• Role legitimacy
• Role adequacy
• Role support

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Conclusions from recent meta-analyses of WHO
Phase III data (Dr. Peter Anderson)

• To enhance the involvement of GPs in the
  management of alcohol problems, a combination of
  both education and support would lead to a
  greater impact than simple education alone
• It is possible to increase the engagement of PHC
  providers in the management of alcohol problems,
  with outcomes similar in size to those in smoking
  cessation and clinical prevention
• The most promising training programmes are
  alcohol-focussed and multi-faceted
• To enhance the involvement of GP, support that
  increases both experience in the management of
  alcohol problems and role security and
  therapeutic commitment is required
• Such support could take the form of onsite agents
  and facilitators

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WHO Phase IV study (English arm)Focus Groups

• Primary Health Care Teams (4)
• GPs and Practice Nurses (22)
• Patients (6)

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Primary Health Care Teams

• Practices stratified into 2 groups
• previous experience of Drink-less programme in
  Phase III
• no previous experience
• PHC professionals perspectives on either
• content and delivery of SBI/ AUDIT and
• Drink-less programme
• uptake and implementation of the programme

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GPs Practice Nurses

• Separate focus groups held with GPs and practice
  nurses
• Explored differences in GPs and practice nurses
  
• knowledge of alcohol-related issues
• experiences of alcohol screening and
  intervention
• attitudes to discussing alcohol with patients
• to determine different options for SBI

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Patients

• 10 practices recruited
• Random sample of patients invited from practice
  lists
• Focus groups stratified by age and gender
• Patients perspectives on
• excessive or risky drinking
• content and delivery of SBI in primary health
  care
• AUDIT and Drink-less Programme

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Results (1)Current barriers to alcohol work in
PHC

• Little or no formal training of PHC professionals
• Confusion over recommended levels and appropriate
  advice
• Difficulty in assessing consumption accurately
• Difficulty in discussing alcohol-related issues
• Lack of time in a consultation

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Results (2)Current opportunities for alcohol
work in PHC

• Practice nurses routinely ask patients about
  lifestyle factors including alcohol
• Patients expect and dont mind being asked about
  alcohol in certain contexts
• Alcohol recognised by practice teams as being an
  important part of work in PHC

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Results (3)Screening methods

• Routine screening in new patient registrations,
  general health checks, specific clinics etc.
• Incorporate AUDIT into general health and
  lifestyle questionnaire
• Opportunistic screening in GP consultation when
  triggered by presenting problem
• ?voluntary screening by patients in waiting room

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Results (4)Brief intervention procedures

• Intervention during medical checks, specific
  clinics etc.
• Intervention tailored to individual patients
• Information tailored specifically for different
  patient groups
• Training in raising alcohol-related issues and
  brief intervention skills

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Results (5)Responsible personnel respective
roles

• GPs
• first choice for most patients
• perceived by some patients as too busy to talk
• GP has little time in average consultation (7
  mins)
• opportunistic SBI related to presenting problem
• referral to trained nurse or alcohol worker

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Results (6)Responsible personnel respective
roles

• Practice nurses
• first line in assessment and advice
• perceived as having more time to talk
• concerned about increased workload
• routine SBI in specified clinics etc.
• support and monitoring of patients
• referral to GP or alcohol worker/CPN

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Results (7)Responsible personnel respective
roles

• Alcohol workers in PHC
• appropriate for patients with more severe
  problems
• perceived stigma attached to alcohol worker in
  primary care setting
• brief intervention, motivational interviewing
• support and monitoring of patients
• training and support for PHC teams

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Results (8)Responsible personnel respective
roles

• Health visitor
• District nurse
• Counsellor
• CPN
• Dietician
• Health/lifestyle advisor

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Wider implementation issues

• Need to disseminate evidence of effectiveness of
  SBI
• Need for alcohol specific team-based training
• Time/resources to deliver SBI essential
• On-going support from specialist alcohol services
  essential
• Implementation of the National Alcohol Strategy

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CONCLUSIONS FROM DELPHIEncouraging PHC
professionals to deliver SBI

• There were a range of measures that were
  supported as means to encourage PHC professionals
  to routinely deliver SBI, without any of these
  clearly being singled out as more effective in
  this respect than the rest
• The development of a National Alcohol Strategy
  was included in these strongly supported measures
  
• There was no consensual support for two measures
  that are sometimes proposed in this regard
  adding alcohol to the GP contract and offering
  financial incentives for this work

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CONCLUSIONS FROM DELPHICommunicating the
concept of risky drinking to the general public

• A number of measures were strongly supported
  consistent risk messages, not just at Christmas
  using different information for different groups,
  e.g. young, pregnant etc. work in schools linked
  to smoking and sex education a new language away
  from alcoholic
• Using a National Alcohol Strategy to send a clear
  message about risk drinking was again strongly
  endorsed
• Surprisingly perhaps, measures for which there
  was roughly equal consensus but less agreement
  included "inclusion in Health Improvement
  Programmes" and free telephone information
• Measures that did not show consensus included
  some that are frequently proposed as ways of
  educating the general public about the risks of
  drinking, e.g., using celebrities, public
  awareness campaigns, warnings on alcohol
  advertising, involving local community leaders
  and agencies, and using pints, bottles etc. as
  measures of alcohol consumption rather than
  standard units

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CONCLUSIONSCommunicating the concept of risk
drinking to health professionals

• A few measures were strongly supported - improved
  training and education, clear and consistent
  information on government recommendations, and
  ensuring that specialist services are
  sufficiently well-resourced to enable them to
  develop direct relationships with primary care
• Once more, there was strong support for a
  National Alcohol Strategy in this context
• It is perhaps surprising that, although
  consensually endorsed, utilising PCGs/PCTs,
  articles in health journals and training packages
  gained less agreement than the measures listed
  above
• There was either no consensus, disagreement or
  both with respect to conferences, meetings,
  workshops and training sessions as ways of
  communicating the concept of risky drinking

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CONCLUSIONS FROM DELPHIThe most important
issues concerning SBI in PHC

• There was consensus and strong agreement
  regarding the need for training in risk factors
  and SBI the National Alcohol Strategy making SBI
  a priority a change in overall attitudes towards
  drinking and the need for realism all round
• Statements about which there was no consensus
  included the importance of reaching binge
  drinkers, the prevalence of the medical model in
  medical settings and not using brief intervention
  with patients who are alcohol dependent