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  • pg 1

 Alcohol Screening and
    Brief Intervention
   in Clinical Settings

        Michael Fleming
         Linda Manwell
University of Wisconsin-Madison

    Public Health Paradigm

   The primary goals of alcohol screening
    and brief intervention are to:
     Reduce alcohol use to low-risk levels
     Encourage abstinence in persons who are
      alcohol dependent.
      Why Should Health Care Providers,
      Systems, and Purchasers Care?

   Reduce risk
    (e.g., motor vehicle accidents)

   Reduce alcohol-related problems
    (e.g., depression, suicide, hypertension,

   Reduce alcohol-medication interactions
    (e.g., Xanax. Prozac, Coumadin, Tylenol)
    Why Should Health Care Providers,
    Systems, and Purchasers Care?

 Reduce alcohol-related family violence
  and family stress
 Reduce workplace problems
      (e.g., accidents, performance)
 Save money
 Reduce liability risks
    Interactions of Alcohol and Other
    Health Care Problems

 Smokers who drink relapse at higher rates
 Persons undergoing surgery have higher rates
  of post-operative complications
 Increased risk of liver disease and hepatitis C

 Increased risk of prescription and illicit drug

How Much is Too Much?
Association Between Alcohol Consumption & Mortality
in Men Ages 18-19    50
                                                      Violent death
                                                      Other causes of death




 Andreasson S, et al.
 British Medical Journal.                    0
 1988; 296: 1021-25.
                                                  0       1-100    101-250 251-400   >400
                                                      Weekly alcohol consumption (g)
Estimated Pooled Risk Function Curves:
Alcohol & Cancer Risk                                                        8
                    2.6       Larynx
                    2.4       Oral
                    2.2       Breast
    Relative risk

                    2         Esophagus
                    1.8       Stomach





                          0        20       40      60     80      100
                                    Grams of alcohol/day
  Duffy & Sharples. In: Alcohol & Illness. Edinburgh University Press 1992
Recommended Alcohol Use Limits
for Persons Over Age 21

    For men
     < 15 standard drinks per week
     < 5 standard drinks per occasion

    For women and older adults
     < 8 standard drinks per week
     < 4 standard drinks per occasion
     (14 grams of alcohol = 1 standard U.S. drink)
     90-Day Prevalence in Primary Care                                             10

(n=21,282 patients in 88 primary care clinician offices)

                       At-risk             Problem
                     Drinkers 9%          Drinkers 8%          Alcohol
                                                            Dependent 5%
Drinkers                                                              Abstainers
  38%                                                                    40%

           Manwell, et al. Journal of Addictive Diseases. 1997;17:67-81.
Steps for Alcohol Screening and Assessment
           Step I - Ask about alcohol use
       •Consumption                     •CAGE

                  If consumption is:
   Men:                    >14 drinks/week or >4/occasion
   Women & older adults:   >7 drinks/week or >3/occasion
   Men & women:            1 or more positive CAGE responses

 Step II - Assess for alcohol-related problems
          •Medical          •Alcoholdependence
          •Behavioral       •Readiness to change
Steps for Brief Intervention and Referral
   Step III - Advise appropriate action

  Unable to control use       Alcohol-related problems
  Alcohol dependence          At risk for developing problems

  •Advise  to abstain           •Advise  to cut down
  •Refer to specialist          •Set a drinking goal

          Step IV - Assist and support

            •Consider pharmacotherapy
            •Follow-up visits, phone calls
   Alcohol Screening: To Detect
   At-Risk and Problem Drinkers

 Singlequestion test
 Consumption Questions
   Quantity, frequency, binge
 CAGE family of questionnaires
        Use Disorders Inventory Test
 Alcohol
    Alcohol Assessment Tools
    (Self-Administered, Pencil and Paper)

   Alcohol Dependence Scale (ADS)
   Michigan Alcoholism Screening Test
   Self-Administered Alcohol Screening Test

    Biological Markers

 Blood Alcohol Level (BAL)
 Gamma-Glutamyl Transferase (GGT)

 Mean Corpuscular Volume (MCV)

 Carbohydrate-Deficient Transferrin (CDT)

     Brief Intervention or Talk Therapy

   Commonly used by clinicians to talk to patients
    about chronic health problems or medications.
   Not unique to the alcohol field.
   Helps move people along the readiness to
    change continuum

    Precontemplation                                  Maintenance

               Contemplation Determination   Action
Components of Brief Intervention

 Assessment and direct feedback
 Negotiation and goal setting

 Behavioral modification techniques

 Self-directed bibliotherapy

 Follow-up and reinforcement
      What We Know About Brief

   Can decrease alcohol use for 12 months
   The effect size is similar for men and women
   No difference in effect by age
       Screening & Counseling by a Physician-Nurse
       Team (Israel, Alcohol Clin Exper Res. 1996:20:1443-50)

Site                 Practices of 42 primary care physicians in Cambridge,
                      Ontario, Canada
Population           Men and women ages 30-60 seeking routine care
Selection criteria   Patients reporting trauma in the past 5 years and
                       consumption of >3 drinks/day or ≥5 drinks/occasion
                        or ≥ 2 CAGE responses
Sample size          Exp. n=52, cont. n=53
Intervention         Exp: nurse-delivered, 30-min counseling followed by
                      six 20-min counseling visits x 1 yr. Cont: brief advice.
Follow-up            70% at 12 months
Results              Both groups reduced alcohol use. Experimental sub-
                      jects showed reduced psychosocial problems and GGT.
Collaborative Project on Identification & Treatment of 20
Persons with Harmful Alcohol Consumption
(WHO Brief Intervention Study Group, Am J Public Health. 1996;86:948-55)

Site              WHO collaborating centers in 10 countries
Population        Men and women 18-70 seeking care in hospital,
                  ER, primary care, and health screening settings.
Selection criteria >50 g/day men, >32 g/day women
Sample size       Brief counsel n=576, simple advice n=496, cont n=486
Intervention      Brief counseling: 20-min health interview + alcohol
                  pamphlet + 15 mins of counseling. Simple advice:
                  20-min interview + 5 min advice + alcohol pamphlet.
                  Control: 20-min health interview.
Follow-up         75% at 9 months
Results           Decreased alcohol use & binge in male counseling &
                  advice groups. Reduction in all groups for women.
                  Simple advice as effective as brief counseling.
  Project Health (Ockene, Arch Intern Med 1999:159:2198-2205)

Site                21 physicians & 7 nurse practitioners from 4 primary
                    care internal medicine sites at the U of Massachusetts
Population          Men and women ages 21-70 seeking routine care
Selection criteria >12 drinks/week or 5+/occasion for men; >9 drinks/
                     week or 4+/occasion for women; 2+ positive CAGE
Sample size         Exp. n= 274, cont. n= 256
Intervention       Exp: 5-10 min physician or nurse practitioner patient-
                   centered counseling visit, one follow-up visit, and
                   general health booklet. Cont: General health booklet.
Follow-up          91% at 6 months
Results            Significant reduction in weekly alcohol consumption
                   by both groups. Suggestion of a significant decrease
                   in number of binges in experimental group.
 Alcohol Interventions in a Trauma Center to Reduce                  22

 Injury Recurrence (Gentilello, Ann Surg 1999:230:473-480)
Site               Level 1 trauma center at the Univ of Washington
Population         Men and women ages 18+ presenting to the trauma
Selection criteria Patients screening positive by BAC, GGT, & SMAST
Sample size        Exp. n= 366, cont. n= 396
Intervention       Exp: 30 min motivational interview with psychologist
                   on or near day of discharge and follow-up summary
                   letter mailed one month later. Cont: Routine care.
Follow-up          75% at 6 months, 54% at 12 months
Results            Significant reduction in weekly alcohol consumption
                   in exp group. Also showed 47% reduction in new
                   injuries & 48% reduction in hospital readmissions.
Screening & Brief Intervention for High-Risk College 23
Student Drinkers (Marlatt, J Consult Clin Psychol 1998:66;604-15)

Site               University of Washington
Population         Males and females in their senior year of high school
                   who were accepted to the University of Washington
Selection criteria At least 5-6 drinks on 1 occasion in past month or 3
                   alcohol-related problems on 3-5 occasions in past 3
                   years on the RAPI.
Sample size        Exp. n= 174, cont. n= 174, normative group n=115
Intervention       Exp: Motivational brief intervention session with
                   psychologist in freshman year. Cont: No treatment.
Follow-up          83% at 2 years.
Results            Significant reductions in drinking rates and harmful
                   consequences in experimental group.
       Project TrEAT (Fleming, JAMA 1997:277:1039-45)

Site                64 family physicians, 17 sites, 10 WI counties
Population          Men and women ages 18-64 seeking routine care in
                    community primary care clinics
Selection criteria >14 drinks/wk for men, >11 drinks/wk for women,
                    binge drinking, ≥ 2 positive CAGE responses
Sample size        Exp. n= 392, Cont. n= 382
Intervention       Exp.: 2 physician-delivered 15-min face-to-facevisits,
                   2 follow-up nurse phone calls. Cont: Usual care.
Follow-up         94% at 12 months, 84% at 48 months
Results           Significant reductions in 7-day use, binge episodes,
                  frequency of excessive drinking in experimental group.
                  Also fewer ER visits, hospital days, reduced mortality.
                  Benefit-cost ratio of 43:1 in favor of brief intervention.

(Fleming, et al, 2000, in review)
     Project GOAL (Fleming, J Fam Pract 1999;48:378-84)

History of trial Initiated 1994 to supplement Project TrEAT
Site               43 family physicians, 24 sites, 10 WI counties
Population         Men and women ages 65-85 seeking routine care in
                   community primary care clinics
Selection criteria >11 drinks/wk for men, >8 drinks/wk for women,
                   binge drinking, ≥ 2 positive CAGE responses
Sample size        Exp. n= 87, Cont. n= 71
Intervention       Exp.: 2 physician-delivered 15-min face-to-face visits,
                   2 follow-up nurse phone calls. Cont: Usual care.
Follow-up          92% at 12 months, 88% at 24 months
Results           Significant reduction in 7-day alcohol use, binge
                  use, frequency of excessive drinking in exp group.

Project GOAL (Fleming, et al,              2000, in review)

            Mean Number of Drinks in Past 7 Days (n=158)

 18                         p<.01
                p<.01                   p<.01       p<.02
 12                                                              Control
 10                                                              Experimental
 Baseline       3 months    6 months    12 months    24 months
    What We Know About Brief

 Can decrease emergency department visits
 Can reduce hospital days

 Can reduce accidents and injuries

 Can reduce costs

12-Month TrEAT Data: Utilization Data
                                    Treatment      Control
                                     (n=392)       (n=382)
Health Care Use
Emergency department visits            107           132
Days of hospitalization                126           326

Motor Vehicle Events
Crash with non-fatal injuries          6             9
Crash with property damage only        19            28
Operating while intoxicated            46            52
Other moving violations                 7              6
               (Fleming, et al. Medical Care. 2000;38:7-18)
12-Month TrEAT Data: Benefit-Cost Analysis
                       Benefits (1993 dollars)
                            $ per patient       95% CI        P-value
Medical savings               $523          ($94, $1,093)     <0.05
Legal & motor vehicle
event savings                 $629          ($-488, $1,932) <0.14

Total benefits                $1,152        ($92, $2,257)     <0.0091
Total costs                   $205
Benefits minus costs          $947
Benefit-cost ratio            5.6 : 1
                        (Fleming, et al. Medical Care. 2000;38:7-18)
What We Don’t Know About Brief
   Does brief intervention:
     work for special populations?
     work for more than 12 months?
     reduce morbidity and mortality?
     work in different health care settings?
     work better when combined with pharmacotherapy?
What We Don’t Know About Brief                         32

   Testable implementation strategies:
     Provider interventions
          Educational programs
          Peer review
          Performance-based feedback
          Academic detailing
          Evidence-based clinical guidelines
          Incentives
     Clinic system interventions
          Routine screening
          Reminder systems
          Web and telephone assessment and referral
     Health care system interventions
          Quality improvement

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