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Three Part Question

In [Adult patients attending the emergency department due to alcohol] is [a brief intervention better then no intervention] at [ reducing future alcohol intake]

Clinical Scenario

An adult patient presents to the Emergency Department after an episode of binge drinking. You wonder whether a brief intervention by the alcohol nurse will reduce their drinking in the future

Search Strategy

Using OVID interface:
Medline 1996 to June Week 4 2007
[ethanol.mp. or exp Ethanol or alcohol.mp or exp Alcohol Drinking or booze.mp or alcoholic beverages.mp. or exp Alcoholic Beverages] AND [exp Alcoholic Intoxication/ or alcoholic.mp or alcoholism.mp. or exp Alcoholism or binge drinking$.mp] AND [exp Psychotherapy, Brief or exp Counseling or brief intervention.mp. or exp Behavior Therapy or brief$ interventions$.mp] AND [Emergency Service, Hospital/ or emergency department.mp or accident & emergency.mp] limit to (humans and english language)
Embase 1996 to 2007 Week 27:
[ethanol.mp. or exp Ethanol or alcohol.mp or exp Alcohol Drinking or booze.mp or alcoholic beverages.mp. or exp Alcoholic Beverages] AND [exp Alcoholic Intoxication/ or alcoholic.mp or alcoholism.mp. or exp Alcoholism or binge drinking$.mp] AND [exp Psychotherapy, Brief or exp Counseling or brief intervention.mp. or exp Behavior Therapy or brief$ interventions$.mp] AND [Emergency Service, Hospital/ or emergency department.mp or accident & emergency.mp] limit to (humans and english language)
CINAHL 1982 to June Week 5 2007:
[ethanol.mp. or exp Ethanol or alcohol.mp or exp Alcohol Drinking or booze.mp or alcoholic beverages.mp. or exp Alcoholic Beverages] AND [exp Alcoholic Intoxication/ or alcoholic.mp or alcoholism.mp. or exp Alcoholism or binge drinking$.mp] AND [exp Psychotherapy, Brief or exp Counseling or brief intervention.mp. or exp Behavior Therapy or brief$ interventions$.mp] AND [Emergency Service, Hospital/ or emergency department.mp or accident & emergency.mp] limit to (humans and english language)
Cochrane database of Systematic Reviews 2nd quarter 2007:
[ethanol.mp. or exp Ethanol or alcohol.mp or exp Alcohol Drinking or booze.mp or alcoholic beverages.mp. or exp Alcoholic Beverages] AND [exp Alcoholic Intoxication/ or alcoholic.mp or alcoholism.mp. or exp Alcoholism or binge drinking$.mp] AND [exp Psychotherapy, Brief or exp Counseling or brief intervention.mp. or exp Behavior Therapy or brief$ interventions$.mp] AND [Emergency Service, Hospital/ or emergency department.mp or accident & emergency.mp] limit to (humans and english language)

Search Outcome

Medline found 59 papers, Embase found 45 papers, CINAHL found 10 papers and cochrane found 3 papers. 7 papers were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Barrett B et al 2006 United Kingdom	A total of 599 adults identified as drinking hazardously according to the Paddington Alcohol Test were randomised to referral to an alcohol health worker who delivered a brief intervention (n = 287) or to an information only control (n = 312)	Randomised controlled trial	6 months follow up mean alcohol consumption (units/week)	Brief intervention group 59.7, Control group 83.1, p=0.02. Statistically significant	Baseline data collection was limited due to the busy setting.
			12 month follow up mean alcohol consumption (units/week)	brief intervention group 56.20, Control group 67.20, p=0.09. Statistically not significant
Bazargan-Hejazi S et al 2005 USA	Three bilingual English and Spanish health promotion advocates screened patients from the waiting area of the King Drew Medical Center ED between 9 AM and 6 PM, 5 days a week for 4 months (August 2001 to December 2001). ED patients were eligible for the initial screening if they were aged 18 years or older, spoke English or Spanish, and signed a consent form. Patients were excluded from the study if they reported receiving professional alcohol counseling within the past 12 months, cognitive impairment precluded informed consent, the requirements of medical treatment prevented them from being interviewed, or they were in police custody. Each patient took the AUDIT questionnaire as a baseline marker. Patients were then randomly assigned to either intervention or control groups.	Randomised Controlled trial	Baseline AUDIT scores of 7 to 18: 3 month follow up score compared to baseline score	Intervention group 34% improvement, Control group 13%; P= 0.0099, Odds Ratio= 4.9, 95% confidence Interval 1.2 to 17	Loss of large numbers of both control group and intervention group in follow up
			Baseline AUDIT scores of 19 to 40: 3 month follow up score compared to baseline score	Intervention group 66% improvement, Control group 60%
Crawford MJ et al 2004 United Kingdom	599 Patients were included they had to be Paddington Alcohol Test positive, to be alert and orientated, aged 18 or over, able to speak English sufficiently well to complete study questionnaires, and resident within Greater London. Those already in contact with alcohol services, those already included in the study, and those requesting help with alcohol problems were excluded. Patients were randomised to experimental and control treatment on the basis of simple random sampling using lists derived from a computer program. 312 patients were in control group, 287 in intervention group	Randomized Controlled Trial	6 month follow up comparison of alcohol Units/Weeks consumed	At 6 months intervention group were drinking fewer mean units than control group; t=-2.4 p=0.02	Lack of baseline date and loss of patients on follow up
			12 month follow up comparison of alcohol Units/Weeks consumed	At 12 months intervention group were still drinking less than control but not statistically significant; t=-1.7 p=0.09
Helmkamp JC et al 2003 USA	913 college students, each took the AUDIT questionnaire as a baseline.	Prospective Study	Follow up AUDIT scores	A decrease in AUDIT scores for 78%. Mean decreased from 10.9 to 7.9, a mean difference of 3 points, 95% Confidence Interval: 2.6 - 3.5	No control group for comparison. Loss of patients on follow up. Limited diversity of patient group
D'Onofrio G et Degutis LC 2002 USA	Twenty-seven studies were included. Of these, 21 (n=6,244) were classified as RCTs and 6 (n=1,374) were cohort studies. As well as 14 primary articles included in the 1996 U.S. Preventive Services Task Force Report . 30 RCT's and 9 cohort studies were used to form the recommendations	Systematic Review	Authors recommendation based on review	Brief interventions should be used in the Emergency department	Insufficient information on methods used to avoid Bias in the review
Gentilello, L M R et al 1999 USA	Adults over 18 were included if they met certain criteria such as local residence and if screening was considered positive, Positive was deemed as meeting one of the following five conditions: BAC 100 mg/dl; SMAST score 3; BAC of 1 to 99 mg/dl and SMAST score of 1 or 2; BAC of 1 to 99 and GGT above normal; or SMAST score of 1 or 2 and GGT above normal. 762 patients were randomly allocated into a control (n=396) or intervention group (n=366)	Randomized Controlled Trial	Drinking amount of patients with Baseline smast score of 3 to 8: Baseline compared to at 12 month follow up	Intervention group; 21.6+/-4.2 fewer drinks per week, Controls had an increase of 2.3+/-8.3 drinks per week. P=0.01	Loss of patients on follow up
			In patients designated very low or very high smast scores	No detectable benefit in either group
Wright S et al 1998 United Kingdom	202 Alcohol misusing patients as designated by the Paddington Alcohol Test.	Prospective Study	Follow up at 6 months	65% reported a decrease in alcohol intake	No control group. No randomisation. From original 202 only 110 were able to be followed up.

Comment(s)

There were several good quality trials conducted testing the efficacy of Brief interventions. It appeared that brief interventions had most effect on reducing alcohol intake in drinkers who were not yet alcoholics (hazardous rather than harmful drinkers). In the severe alcoholics it seems that a brief intervention alone is not enough. Many of the patients also proved that it was a cost effective practice.

Clinical Bottom Line

Brief Interventions should be offered to all patients found to be at risk of hazardous drinking.

References

1. Barrett B et al Cost-effectiveness of screening and referral to an alcohol health worker in alcohol misusing patients attending an accident and emergency department: a decision-making approach. Drug & Alcohol Dependence 81(1):47-54, 2006 Jan 4.
2. Bazargan-Hejazi S et al Evaluation of a brief intervention in an inner-city emergency department Annals of Emergency Medicine 46(1):67-76, 2005 Jul
3. Crawford MJ et al Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial Lancet 364(9442):1334-9, 2004 Oct 9-15
4. Helmkamp JC et al Screening and brief intervention for alcohol problems among college students treated in a university hospital emergency department Journal of American College Health 52(1):7-16, 2003 Jul-Aug
5. D'Onofrio G et Degutis LC Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review Academic Emergency Medicine 9(6):627-38, 2002 Jun.
6. Gentilello, L M R et al Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Annals of Surgery 230(4):473-83, 1999 Oct.
7. Wright S et al Intervention by an alcohol health worker in an accident and emergency department Alcohol & Alcoholism 33(6):651-6, 1998 Nov-Dec