Alcohol and Drug Misuse

A Cochrane Handbook

Iosief Abraha, Cristina Cusi

• Publisher: Wiley-Blackwell
• Year: 2012
• Print ISBN: 9780470659694
• eBook ISBN: 9781118454480
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

There is constant pressure for clinicians to practise evidence-based medicine.  Cochrane Reviews are an important source of the evidence which informs clinical decisions but can still require considerable time to read and digest.  This Cochrane Handbook of Alcohol and Drug Misuse serves as a concise guide to the evidence base for relevant interventions, highlighting the key points of Cochrane reviews for the busy practitioner.  

Each review is analysed in a structured format, starting with the question, a brief background and a summary answer, followed by the results presented in comprehensive and concise way. The authors then illustrate the value that the review adds to the current knowledge, the main methodological limitations of the included studies and finally the implications of the review's conclusions for future research.

Addiction to drugs and alcohol is an increasing problem that all clinicians have to deal with. This is especially true for medical and family specialists but more so for those dealing with psychiatric, psychological and social problems.  The benefit of having the evidence underpinning the clinical approach to all aspects of this topic cannot be underestimated. 

The book's comprehensive coverage of interventions provides an authoritative reference for all physicians working with these patients, from family practitioners to clinical specialists and psychiatric specialists. With addiction to drugs and alcohol an increasingly serious morbidity and public health issue, this book from the Cochrane Collaboration will find a wide audience.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from iTunes, Google Play or the MedHand Store.

 

Chapter 1

Effectiveness of Brief Alcohol Interventions in Primary Care Populations¹

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Review Question:

Do brief interventions, delivered in general practice or based in primary care, reduce alcohol consumption in hazardous drinking?

What Is Known of This Topic:

Excessive drinking contributes significantly to social problems, physical and psychological illness, injury and death. Hidden effects include increased levels of violence, accidents and suicide.

One way to reduce consumption levels in a community may be to offer a brief intervention in primary care provided by healthcare workers such as general physicians, nurses or psychologists. The intervention offered includes providing feedback on alcohol use and harms, identifying high-risk situations for drinking and coping strategies, increasing motivation and facilitating the development of a personal plan to reduce drinking. It takes place within the time frame of a standard consultation, 5–15 minutes for a general physician, longer for a nurse.

Summary:

Brief interventions appear to lower alcohol consumption generally in men. The lack of evidence of any difference in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care. Future trials should focus on women and on delineating the most effective components of interventions.

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Last assessment date: 14 February 2007

Objectives:

To assess the effectiveness of brief intervention, general practice and emergency care-based primary care, to reduce alcohol consumption. To assess whether outcomes differ between trials in research settings and those in routine clinical settings. Primary outcomes: Self- or other reports of drinking (quantity and frequency), levels of laboratory markers and alcohol-related harm to the drinkers or to affected others. Other outcomes: Patient satisfaction measures and health-related quality of life.

Study Population:

Patients who are routinely presenting to primary care for a range of health problems and whose alcohol consumption is identified as being excessive or who have experienced harm as a result of their drinking behaviour.

Search Strategy:

The Cochrane Drug and Alcohol Group’s Specialised Register, MEDLINE, EMBASE, CINAHL, PsycINFO, Science Citation Index, Social Science Citation Index (February 2006), Alcohol and Alcohol Problems Science Database (1972–2003) and reference lists of articles.

Results:

Twenty-two randomised trials with 7619 participants were included.

After follow-up of 1 year or longer, brief intervention had lower alcohol consumption than the control group (weight mean difference: −38 grams/week (95% CI: −54 to −23); heterogeneity between trials: I² = 57%).

Subgroup analysis (eight studies with 2307 participants) confirmed the benefit of brief intervention in men (mean difference: −57 grams/week (95% CI: −89 to −25), I² = 56%), but not in women (mean difference: −10 grams/week (95% CI: −48 to 29). I² = 45%). Meta-regression showed little evidence of a greater reduction in alcohol consumption with longer treatment exposure or among trials which were less clinically representative.

Extended intervention was associated with a non-significantly greater reduction in alcohol consumption than brief intervention (mean difference: −28, 95% CI: −62 to 6 grams/week, I² = 0%).

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What This Review Adds to the Current Knowledge:

Pooled analyses from a significant number of studies document that brief alcohol intervention in primary care contexts results in significant reductions in weekly consumption for men, with an average drop of about six standard drinks per week in patients compared to controls. The review showed no significant reduction in alcohol consumption for women; although this may be partly due to low statistical power (as trials reporting outcomes from women enrolled only 499 participants), brief interventions for women are not yet justified.

Main Limitations:

A moderate level of heterogeneity. Another most likely source of bias is loss to follow-up, which was about 27% overall and significantly higher in the brief intervention arm than in the control arm (difference in rates of 3%, 95% CI: 1% to 6%).

The Future:

There is a clear need for more evaluative research on brief interventions with women, younger people and those from cultural minority groups. However, given the large number of trials of brief alcohol intervention showing a positive impact in men, there is no need for more of the same before such interventions are delivered in primary care. Longer treatment appeared to have little effect in significantly improving outcomes. Moreover, there is some suggestion that screening alone may result in alcohol consumption reduction, and this should be investigated further. Finally, future research directions should focus on implementation issues including a more precise specification of brief intervention components.

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Figure 1.1 Brief intervention versus control, outcome: quantity of drinking (g/week) subgrouped by effectiveness and efficacy.

Reproduced from Kaner EF, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007(2):CD004148, with permission from John Wiley & Sons Ltd. Copyright © 2007 The Cochrane Collaboration.

Reference

1 Kaner EF, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007(2):CD004148. Epub 2007/04/20.

Chapter 2

Brief Interventions for Heavy Alcohol Users Admitted to General Hospital Wards¹

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Review Question:

Are brief interventions effective to reduce alcohol consumption and to improve outcomes for heavy alcohol users admitted to general hospital inpatient units?

What Is Known of This Topic:

Research suggests that a high number of patients admitted to general hospitals experience alcohol-related problems, often unrelated to the conditions they were admitted to treat.

Admission to hospital as an inpatient, in general medical wards and trauma centres, provides an opportunity whereby heavy alcohol users are accessible, have time for an intervention and may be made aware of any links between their hospitalisation and alcohol. Traditionally, interventions are offered only when individuals were diagnosed as alcohol dependent, though recent evidence has suggested benefits from intervening earlier using screening and brief interventions. Brief interventions involve a time-limited intervention that focuses on changing behaviour.

Summary:

Brief interventions to heavy alcohol users admitted to general hospital wards are beneficial in terms of reduction in alcohol consumption and death rates. However, these findings are based on studies involving mainly male participants.

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Last assessment date: 16 May 2011

Objectives:

To determine whether brief interventions reduce alcohol consumption and improve outcomes for heavy alcohol users admitted to general hospital inpatient units. Primary outcomes: Alcohol consumption. Secondary outcomes: Hospital re-admission rates, mortality rates, alcohol-related injuries, quality of life, reduction in adverse legal events and reduction in need for institutional care.

Study Population:

Adults (16 years or older) admitted to a general hospital for any reason other than alcohol treatment, consuming alcohol above the recommended safe weekly or daily amounts for the country in which the study took place.

Search Strategy:

The Cochrane Drug and Alcohol Group Register of Trials, Cochrane Central Register of Controlled Trials, MEDLINE, ...

Table of contents

• Cover
• Title page
• Copyright page
• Foreword
• Preface
• Acknowledgements
• Part 1: Alcohol
• Part 2: Drugs
• Index