Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis

BACKGROUND: Numerous trials of the efficacy of brief alcohol intervention have been conducted in various settings among individuals with a wide range of alcohol disorders. Nevertheless, the efficacy of the intervention is likely to be influenced by the context. We evaluated the evidence of efficacy of brief alcohol interventions aimed at reducing long-term alcohol use and related harm in individuals attending primary care facilities but not seeking help for alcohol-related problems. METHODS: We selected randomized trials reporting at least 1 outcome related to alcohol consumption conducted in outpatients who were actively attending primary care centers or seeing providers. Data sources were the Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, ISI Web of Science, ETOH database, and bibliographies of retrieved references and previous reviews. Study selection and data abstraction were performed independently and in duplicate. We assessed the validity of the studies and performed a meta-analysis of studies reporting alcohol consumption at 6 or 12 months of follow-up. RESULTS: We examined 19 trials that included 5639 individuals. Seventeen trials reported a measure of alcohol consumption, of which 8 reported a significant effect of intervention. The adjusted intention-to-treat analysis showed a mean pooled difference of -38 g of ethanol (approximately 4 drinks) per week (95% confidence interval, -51 to -24 g/wk) in favor of the brief alcohol intervention group. Evidence of other outcome measures was inconclusive. CONCLUSION: Focusing on patients in primary care, our systematic review and meta-analysis indicated that brief alcohol intervention is effective in reducing alcohol consumption at 6 and 12 months.     

Causative and intervening factors of harmful alcohol consumption and cannabis use in Malawi

The aim of this study was to identify culturally relevant factors in the causation of and intervention in harmful alcohol and cannabis use in Malawi. Therefore a community research was conducted through key informants, and subjects were followed up for 6 months. The data were analyzed and interpreted according to an African model of socialization and personhood. It was concluded that traditional intervention strategies on a social and community level are no longer effective in the transitional Malawian, and that strategies aiming at basic life-style changes like those in some "Healing Churches" are called for.     

Access to alcohol outlets and harmful alcohol consumption: a multi-level study in Melbourne, Australia

Aims To assess the association between access to off‐premises alcohol outlets and harmful alcohol consumption. Design, setting and participants Multi‐level study of 2334 adults aged 18–75 years from 49 census collector districts (the smallest spatial unit in Australia at the time of survey) in metropolitan Melbourne. Measurements Alcohol outlet density was defined as the number of outlets within a 1‐km road network of respondents' homes and proximity was the shortest road network distance to the closest outlet from their home. Using multi‐level logistic regression we estimated the association between outlet density and proximity and four measures of harmful alcohol consumption: drinking at levels associated with short‐term harm at least weekly and monthly; drinking at levels associated with long‐term harm and frequency of consumption. Findings Density of alcohol outlets was associated with increased risk of drinking alcohol at levels associated with harm. The strongest association was for short‐term harm at least weekly [odds ratio (OR) 1.10, 95% confidence interval (CI) 1.04–1.16]. When density was fitted as a categorical variable, the highest risk of drinking at levels associated with short‐term harm was when there were eight or more outlets (short‐term harm weekly: OR 2.36, 95% CI 1.22–4.54 and short‐term harm monthly: OR 1.80, 95% CI 1.07–3.04). We found no evidence to support an association between proximity and harmful alcohol consumption. Conclusions The number of off‐premises alcohol outlets in a locality is associated with the level of harmful alcohol consumption in that area. Reducing the number of off‐premises alcohol outlets could reduce levels of harmful alcohol consumption.     

Estimating alcohol consumption.

Alcohol use is one of the two main aetiologies of acute pancreatitis. Detection of excessive alcohol consumption is problematic, illustrated by the fact that self-reports of alcohol consumption account for only approximately 50% of the reported sales of alcohol. To improve the reliability, structured questionnaires and various biochemical markers have been developed to estimate alcohol consumption objectively. Further, the pattern of drinking and level of consumption within the past 2 weeks may alter the clinical picture of the acute pancreatitis. The aim of this paper is to remind the clinician of the importance of accurate and complete history, the need to document the actual alcohol consumption, pattern of drinking, clinical signs of alcoholism and to use biochemical tests and sometimes questionnaires.     

Hazardous alcohol consumption and alcohol-related problems are associated with unknown and HIV-positive status in fishing communities in Uganda

In Uganda, alcohol consumption is associated with higher HIV prevalence. However, research is needed to better understand how different patterns of alcohol consumption and alcohol-related problems may drive this association. In this cross-sectional study, we examined how hazardous alcohol use and alcohol-related problems such as psychological, physical, and social harms are associated with HIV status in fishing communities in Uganda. 300 (132 male, 168 female) residents of fishing communities in Uganda (75 participants from each of the following occupational groups: fishmongers, alcohol sellers, commercial sex workers (CSW), and fishermen) completed an interviewer-assisted computerized interview. We captured information on sociodemographics and HIV testing history. Prior 12-month hazardous alcohol consumption patterns and alcohol-related problems were assessed with the AUDIT and AUDADIS. 19.7%, 58.0%, and 23.3% of the sample reported being HIV positive, being HIV negative from a test within the prior 12 months, and not knowing their HIV status respectively. 18.7% reported the co-occurrence of hazardous alcohol consumption patterns and alcohol-related problems. 7.7% reported either hazardous alcohol consumption patterns or alcohol-related problems. Compared to non-drinkers, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of being HIV positive (adjOR 2.75, 95% CI 1.17–6.43) and of unknown HIV status (adjOR 3.35, 95% CI 1.52–7.42). Reporting only hazardous consumption levels, only alcohol-related problems, or low-risk drinking, did not increase the odds of being HIV positive or of unknown status. Among those not HIV positive, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of never having had an HIV test (adjOR 3.78, 95% CI 1.63–8.68). The co-occurrence of hazardous alcohol use and alcohol related problems appears to be a prominent risk factor for HIV infection, not knowing one's HIV status, and never testing for HIV in this setting.     

Addressing alcohol use among primary care patients

Objectives: To determine whether rates of addressing alcohol use differed between family medicine and internal medicine residents, and to determine whether attitudes, confidence, and perceptions affected these relationships. Setting: Two university outpatient clinics, one staffed by family medicine and the other by primary care and categorical internal medicine residents. Design: Cross-sectional study of consecutive patients who had been followed by second- and third-year residents for at least one year. Measurements: Alcohol abuse was determined using the Michigan Alcoholism Screening Test (MAST), with a score a 5 considered positive. Rates of addressing alcohol use in the preceding year were determined by patient report and chart review. Attitudes were assessed using the Substance Abuse Attitude Survey (SAAS). Results: 334 patients of 49 residents completed the MAST. Rates of alcoholism among the patient groups were: family medicine, 8.3%; primary care, 29.1%; and categorical medicine, 18.0% (p<0.001). Screening behavior varied by type of residency: 47% of the family medicine, 71% of the primary care, and 65% of the categorical residents’ patients reported being asked about alcohol use in the preceding year (p<0.001); chart documentation was present for 15% of the family medicine, 38% of the primary care, and 24% of the categorical residents’ patients (p<0.001). Perceived prevalence of alcohol abuse, confidence in intervening, and several scales on the SAAS were related to residency type and to addressing alcohol use, but controlling for these variables did not affect the association between residency type and either patient report or chart documentation of screening. Conclusion: Rates of addressing alcohol use differed for internal medicine and family medicine residents, but were not due to differences in resident perceptions and attitudes. Supported in part by the Center for Substance Abuse Prevention, grant number AA07526.     

Prevalence of hazardous and harmful consumption of alcohol in the insured population of the Mexican Social Security Institute

OBJECTIVE: To estimate the prevalence of hazardous and harmful alcohol consumption among the insured population of Instituto Mexicano del Seguro Social (Mexican Social Security Institute, IMSS). MATERIAL AND METHODS: A cross-sectional survey was conducted in 45,117 insured subjects from Mexico's 36 political districts; study subjects were interviewed using a structured and self-applied questionnaire on alcohol consumption, using the ten-item screening instrument AUDIT (Alcohol Use Disorder Identification Test). The first three questions refer to the amount and frequency of drinking, the following three question to alcohol dependence, and the last four to alcohol-related problems. Each item has three to five options and each is scored progressively from zero to four. The prevalence of alcohol consumption was estimated with 95% confidence intervals. RESULTS: The prevalence of problem drinkers (hazardous and harmful) was 12.8% (IC 95% 12.5-13.2); it was higher in men (22.2%; IC 95% 21.7-22.8) than in women (3.4%; IC 95% 3.1-3.6). An age effect was observed in men, while in women alcohol consumption was more homogeneous. In both genders consumption was higher in productive-age groups. CONCLUSIONS: The prevalence of hazardous and harmful alcohol consumption is high in the insured population of the IMSS in Mexico. There is a need to implement health policies and health programs to diminish this serious health problem. The English version of this paper is available at: http://www.insp.mx/salud/index.html.     

Effects of alcohol control measures on alcohol consumption.

This paper first very briefly discusses different kinds of alcohol control measures, and after that reviews the available studies of the effects of control measures on alcohol consumption. During recent years the field of evaluation of alcohol control measures has matured and drawn on new technologies. The new prevention evaluation literature has also taken several directions. Taken together, the results of various studies have very clearly shown that control measures can influence drinking patterns, and in turn the rate of drinking problems. However, effects of changes in alcohol prices and availability are also determined by the social, cultural, and economic circumstances characteristic to each country and period.     

The alcohol-related problems survey: identifying hazardous and harmful drinking in older primary care patients

OBJECTIVES: Older adults can incur problems at low levels of alcohol consumption because of age-related physiological changes, declining health and functional status, and medication use. We have developed and tested a screening measure specifically for older people, the Alcohol-Related Problems Survey (ARPS), to identify older adults with these risks. DESIGN: Survey. SETTING: Academic and community primary care clinics. PARTICIPANTS: Five hundred forty-nine current drinkers aged 65 and older, mostly white with high school or more education. MEASURES: Alcohol use was classified as harmful, hazardous, or nonhazardous depending upon consumption alone or combined with selected comorbidities and medication use. Harmful drinking (including alcohol abuse or dependence) means the presence of problems (e.g., hypertension, adverse drug events, legal problems) due to drinking. Hazardous drinking means risks for problems are likely. Nonhazardous drinking poses no known risks for problems. RESULTS: Eleven percent of subjects were harmful drinkers and 35% were hazardous drinkers. Harmful drinking was more common in men than women and in persons younger than 75 than those aged 75 and older. Similar proportions of men and women and younger and older age groups were hazardous drinkers. Most harmful drinkers were identified by their use of alcohol with their comorbidity, whereas most hazardous drinkers were identified by their use of alcohol with medications. Test-retest reliability was substantial (kappa = 0.65). CONCLUSION: Physicians are urged to screen for alcohol-related problems in older persons. The ARPS reliably identifies harmful, hazardous, and nonhazardous drinking in older adults resulting most often from the interaction between alcohol and disease and medication use.     

Prevalence and recognition of alcohol abuse in a primary care population

PURPOSE: The purpose of this study was to assess the prevalence, physician recognition, and treatment of alcohol abuse among patients of 19 senior medical residents practicing in a hospital-based, primary care setting. PATIENTS AND METHODS: Interviews of 242 outpatients were conducted, and alcohol abuse and dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), were determined using the Diagnostic Interview Schedule. RESULTS: Twenty percent of the patients studied had abused or were dependent on alcohol at some time in their lives and 5 percent reported abuse or dependence within the last year. Of the techniques studied, a short screening questionnaire (Short Michigan Alcohol Screening Test [SMAST]) was the most accurate way of identifying patients who abused alcohol, and physician assessments were more accurate than laboratory tests. Although the physicians were aware of serious alcohol problems among 77 percent of their patients who met DSM-III criteria for alcohol abuse or dependence in the previous year, they identified only 36 percent of their patients with less serious problems or past alcohol abuse. They had only discussed alcohol abuse with 67 percent of the patients they identified as alcohol abusers. CONCLUSION: We conclude that a short screening questionnaire (SMAST) is an accurate means of identifying alcohol abuse. Despite the recognition of serious alcohol problems by the physicians, the problem is not addressed routinely even among patients that are recognized as alcoholic.     

A temporal and dose-response association between alcohol consumption and medication adherence among veterans in care

BACKGROUND: Previous studies have shown that alcohol consumption is associated with decreased medication adherence, but this association may be confounded by characteristics common among those who drink heavily and those who fail to adhere (e.g., illicit drug use). Our objective was to determine whether there are temporal and dose-response relationships between alcohol consumption and poor adherence. METHODS: We administered telephone interview surveys to participants in the Veterans Aging Cohort Study, an eight-site observational study of HIV+ and matched HIV- veterans in care, to determine whether alcohol consumption on a particular day was associated with nonadherence to prescribed medications on that same day. We used the Time Line Follow Back to measure alcohol consumption and the Time Line Follow Back Modified for Adherence to measure adherence. Individuals were categorized as abstainers (no alcohol in past 30 days), nonbinge drinkers (alcohol in past 30 days but < or =four standard drinks on each day), or binge drinkers (> or =five standard drinks on at least one day). RESULTS: Among 2702 respondents, 1582 (56.6%) were abstainers, 931 (34.5%) were nonbinge drinkers, and 239 (8.9%) were binge drinkers. Abstainers missed medication doses on 2.4% of surveyed days. Nonbinge drinkers missed doses on 3.5% of drinking days, 3.1% of postdrinking days, and 2.1% of nondrinking days (p < 0.001 for trend), and this trend was more pronounced among HIV+ individuals than HIV- individuals. Binge drinkers missed doses on 11.0% of drinking days, 7.0% of postdrinking days, and 4.1% of nondrinking days (p < 0.001 for trend), and this trend was comparably strong for HIV+ and HIV- individuals. CONCLUSIONS: Among veterans in care, self-reported alcohol consumption demonstrates a temporal and dose-response relationship to poor adherence. HIV+ individuals may be particularly sensitive to alcohol consumption.     

Hazardous drinkers and drug users in HMO primary care: prevalence, medical conditions, and costs

BACKGROUND: There exists substantial evidence that individuals with alcohol and drug disorders have heightened comorbidities and health care costs. However, little is known about the larger population of "hazardous" drinkers (those whose consumption increases their "risk of physical and psychological harm") and drug users. METHODS: A sample of 1,419 patients from HMO primary care clinics was screened for hazardous drinking and drug use. Health plan databases were used to examine medical conditions and health care costs of hazardous drinkers and drug users in the year prior to screening, in comparison to 13,347 patients from the same clinics, excluding those screened. RESULTS: We found a prevalence of 7.5% for hazardous drinking and 3.2% for drug use in primary care (10% had at least one of the two problems). Hazardous drinkers and drug users had heightened prevalences for eight medical conditions, including costly conditions such as injury and hypertension, and psychiatric conditions. Medical costs for the year examined were not higher, except for those who also had psychiatric conditions. CONCLUSIONS: The prevalence of hazardous drinking and drug use was similar to hypertension and diabetes. Hazardous drinkers and drug users' heightened medical conditions, especially those related to alcohol and drug abuse, indicate that screening and brief intervention at this lower threshold of hazardous drinking and drug use will detect individuals with health risks sooner. Optimal treatment and prevention of some medical disorders may require identification and intervention of underlying hazardous alcohol or drug use.