ICAA meeting Alcohol education in Switzerland Brief Alcohol Intervention

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ICAA meeting Alcohol education in
SwitzerlandBrief Alcohol Intervention

• Dr Jean-Bernard Daeppen
• Alcohol Treatment Center
• CHUV - Lausanne University Hospital

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Outline

• Definition
• What we know
• What we may know and what we dont know
• Summary

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Outline

• Definition
• What we know
• What we may know and what we dont know
• Summary

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Definition

• Individual counseling
• Duration 5 to 45 minutes
• Aim at reducing alcohol use or alcohol related
  behaviors
• Generally focuses on hazardous drinkers without
  dependence
• Content varies from simple to advice to more
  complex counseling

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Definition

• In the late 90s, effective BI were associated to
  the FRAMES components
• Giving a Feedback, put some Responsibility on the
  subject, give some kind of Advice to reduce
  drinking, give a Menu of possible options, adopt
  an Empathic style, and support subjects
  Self-efficacy

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Outline

• Definition
• What we know
• What we may know and what we dont know
• Summary

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Systematic Evidence Review Very Brief and Brief
InterventionsConsumption Outcomes
Very brief
US Preventive Services Task Force. Ann Intern Med
2004140557-68.
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Systematic Evidence Review Brief Multi-contact
InterventionsConsumption Outcomes
US Preventive Services Task Force. Ann Intern Med
2004140557-68.
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Systematic Reviews and Meta-analyses
Non-significant differences
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Efficacy of Brief Intervention

• Proportion of drinkers of risky amounts decreased
  from 69 (942/1374) to 57 (810/1410)
• Consumption decreased 15 (by 38 grams per
  week)(n5639)

Beich et al. BMJ 2003327536 Bertholet et al.
Arch Intern Med. 2005165986
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Summary What we know

• Brief intervention decreases drinking at 1 year
  in non-dependent excessive drinkers

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Outline

• Definition
• What we know
• What we may know and what we dont know
• Summary

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What might we know?What dont we know?

• Efficacy for drinking consequences
• Effectiveness (as distinguished from efficacy)
• Generalizability (populations, settings,
  practitioners)
• Cost-utility (cost-effectiveness)
• Why do brief intervention work?

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Project TrEAT

• N 774 men and women drinking risky amounts,
  from 17 US primary care practices 93 follow-up
  (1 yr) 83 follow-up (4 yrs)
• Randomized to receive
• A general health booklet (control)
• A general health booklet plus two 15-minute
  physician alcohol discussions and a nurse
  telephone call

Fleming MF, Lawton Barry K, et al. JAMA
19972771039
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Project TrEATlong term outcome
significant decrease Fleming MF et al. Alcohol
Clin Exp Res. 200226(1)36-43.
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The Malmö Studylong term outcome

• Population-based cohort of middle-aged men
  identified by screening with upper decile GGT as
  isolated abnormality and at least 20 g alcohol
  daily
• Randomized to
• GGT RN q mo, MD q 3 mo
• Letter - GGT is high, restrict alcohol, F/U in 2
  years
• 78 follow-up (4 years)

Kristenson H, et al. Alcohol Clin Exp Res
19837203
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The Malmö Study

• 5-year hospital utilization decreased by 50 in 5
  years (total approx. 1600 vs 800 days, mainly
  alcohol-related)
• Sick days decreased in intervention group
• GGT decreased in both groups (4 yrs)
• 16-year mortality decreased in intervention group
• Total mortality 10 vs. 14 (NS)
• Alcohol-related (48 of all deaths) 4 vs. 7
  (p0.03)

Kristenson H, et al. Alcohol Clin Exp Res
19837203
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Efficiency/Effectiveness

• Screening 1000 people in general practice
• Yields 90 drinking risky amounts
• 30 receive brief intervention
• 2-3 people benefit (NNT approximately 10)

Based on screening and entry into RCTs.
Actual number likely higher. Number from RCTs.
Better estimate may be 56-74 of those identified
(Saitz et al. Annals Int Med 2003138372-82).
Beich et al. BMJ 2003327536
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Efficiency/Effectiveness

• Type and magnitude of outcomes
• 57 vs. 69 risky amounts
• 38 g per week decrease
• ? Consequences

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Sample Exclusion Criteria

• Men who drank more than 14 drinks a week, women gt
  11 but not gt 50
• Pregnancy
• lt age 18, gt 65
• Alcohol treatment in past year
• Symptoms of withdrawal in past year
• Received physician advice in past 3 months to
  change alcohol use
• Suicide symptoms

Fleming MF, Lawton Barry K, et al. JAMA
19972771039
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Alcohol Dependence

• Usually excluded from brief intervention versus
  placebo or usual care studies
• Brief intervention similar in efficacy to more
  extensive care (20 studies in treatment seekers)

Moyer A et al. Addiction 200297279
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General Hospital SettingSystematic Review

• 8 controlled studies (all not randomized), 1597
  adults
• 2 in outpatient departments
• 6 in inpatients (orthopedics, medicine, surgery)
• 4/6 studies decreased alcohol-related problems
• 1/7 studies decreased consumption (outpatients)
• 2/4 studies decreased serum GGT levels

Emmen MJ et al. BMJ 2004328(7435)318
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Trauma Services

• Screening and brief intervention
• 12-month drinking decreased (22 vs. 7 / week)
  (follow-up among 54 of those randomized)
• NS Reduction in emergency care or trauma
  admission to same center for injury (HR 0.52, 95
  CI 0.26-1.07)
• NS Reduction in hospital admission for injury
  statewide (HR 0.52, 95 CI 0.21-1.29)

NS non-significant
Gentilello LM et al. Ann Surg 1999230473
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Injured Subjects, EmergencyIntervention Effects

• Monti
• Fewer consequences All decreased drinking.
• Longabaugh
• Fewer consequences and alcohol-related injuries
  with intervention All decreased drinking.
• Sommers Dyehouse (unpublished)
• Two negative studies
• Mello
• Secondary analysis MVC injured (but not MVC
  uninjured) decreased drinking

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Emergency Department

• Screening and brief intervention in 1300
  randomized patients
• 12-month drinking decreased (30 in brief
  intervention, similar reduction in 2 control
  groups) (follow-up among 78 of those
  randomized)
• No difference observed in subgroups (age, gender,
  trauma severity, alcohol dependence)
• The no difference across groups observed may be
  explained by
• Brief intervention in ED has no effect
• A trauma effect
• A Hawthorne effect
• A regression to the mean effect

Daeppen et al, Addiction, in press
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Populations

• Adolescents
• 2 studies (emergency department)
• Age 18-19 intervention associated with less
  drinking and driving, traffic violations, and
  alcohol-related problems
• Age 13-17 no differences in consumption,
  drinking and driving, alcohol-related injuries or
  problems
• Pregnant women
• 4 studies no significant differences between
  intervention and control
• Older adults
• 1 study reduction in consumption with BI (92 12
  month follow-up of N158 of 6073 screened)

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Multiple Risk BehaviorsThe Norm

• 52 of adults in the US have gt1 behavioral risk
  factor (of 4 inactivity, overweight, smoking,
  risky drinking)
• 6 systematic reviews of addressing multiple
  behavioral risks
• 1 of 3 studies targeting risky drinking in
  secondary prevention of hypertension decreased
  use
• 1 study of primary prevention of hypertension did
  not
• 1 study of smoking, diet, exercise and alcohol
  had no effect on drinking or smoking

Goldstein MG et al. Am J Prev Med
200427(2S)61-79 Coups EJ et al. Am J Prev Med
200427(2S)34-41.
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Cost-Benefit of Screening and Brief Intervention

• Emergency department and hospital for trauma
  patients net benefit per patient screened, 3
  years
• 89 in healthcare costs saved
• Primary care net benefit per patient screened, 4
  years
• 546 medical costs
• 7780 healthcare and other costs (MVCs)
  including lost wages, property damage, pain and
  suffering

Gentilello LM et al. Ann Surg 2005241(4)541-50.
Fleming MF et al. Alcohol Clin Exp Res.
200226(1)36-43.
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Cost-outcome Analysis of Screening and Brief
Intervention

• Emergency department cost per unit decrease in
  outcome, 3 months
• 258 / AUDIT point
• 219 / drink per week
• 61 / heavy drinking
• cost of SBI only

Kunz FM et al. J Stud Alcohol 200465(3)363-70.
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Implementation

• Literature review and inquiry in 500
  representative primary care doctors about brief
  intervention implementation in Switzerland
• Obtained and analyzed 238 questionnaires

Daeppen and Gaume, 2005
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Literature review
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Self perception of knowledge and skills regarding
alcohol
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Ingredients of efficacyBrief intervention
revisited

• The importance of motivational interviewing
  findings regarding brief intervention
• The backfire effect of feedback
• The importance of empathy (listening and
  understanding) vs structured intervention
  including closed questions
• The importance of change talk and commitment talk

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The new face of a brief intervention

• Focus on multiple behaviors and consequences
• Focus on the exploration of a potential changes
  in use and consequences of use
• Use other MI skills such as active listening,
  learn to avoid using righting reflex, never push
  the patient/client to commit to change when not
  ready to
• Improve clinicians skills on MI style rather than
  structured easy to learn brief intervention

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What we might/dont knowSummary

• Long term effect
• Effectiveness
• Generalizability to unselected samples
• Subgroups adolescents, older adults, pregnant
  women, alcohol dependence, multiple risks
• Settings hospital, emergency department/trauma,
  community
• Ingredients of efficacy clinicians, training,
  content, style, duration, booster session.
• Effects on outcomes beyond consumption
• Cost-effectiveness

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Outline

• Definition
• What we know
• What we may know and what we dont know
• Summary

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Summary

• Brief intervention can have efficacy for
  decreasing consumption modestly in nondependent
  drinkers of risky amounts in general healthcare
  settings (primary care)
• Broad effectiveness and cost-effectiveness are
  less clear
• The content and mechanisms of efficacy of brief
  intervention should be further explored