Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse

382 Pages·2012·3.11 MB·English

Comparative Effectiveness Review
Number 64
Screening, Behavioral
Counseling, and Referral
in Primary Care To Reduce
Alcohol Misuse
Comparative Effectiveness Review
Number 64

Screening, Behavioral Counseling, and Referral in
Primary Care to Reduce Alcohol Misuse

Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov

Contract No. 290-2007-10056-I

Prepared by:
RTI International–University of North Carolina Evidence-based Practice Center
Research Triangle Park, NC

Investigators:
Daniel E. Jonas, M.D., M.P.H.
James C. Garbutt, M.D.
Janice M. Brown, Ph.D.
Halle R. Amick, M.S.P.H.
Kimberly A. Brownley, Ph.D.
Carol L. Council, M.S.P.H.
Anthony J. Viera, M.D., M.P.H.
Tania M. Wilkins, M.S.
Cody J. Schwartz, M.P.H.
Emily M. Richmond, M.P.H.
John Yeatts, M.P.H
Tammeka Swinson Evans, M.O.P.
Sally D. Wood, B.A.
Russell P. Harris, M.D., M.P.H

AHRQ Publication No. 12-EHC055-EF
July 2012
This report is based on research conducted by the RTI International–University of North
Carolina Evidence-based Practice Center under contract to the Agency for Healthcare Research
and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10056-I). The findings and
conclusions in this document are those of the author(s), who are responsible for its contents; the
findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no
statement in this report should be construed as an official position of AHRQ or of the U.S.
Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and
clinicians, health system leaders, and policymakers, among others—make well-informed
decisions and thereby improve the quality of health care services. This report is not intended to
be a substitute for the application of clinical judgment. Anyone who makes decisions concerning
the provision of clinical care should consider this report in the same way as any medical
reference and in conjunction with all other pertinent information, i.e., in the context of available
resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice
guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage
policies. AHRQ or U.S. Department of Health and Human Services endorsement of such
derivative products or actions may not be stated or implied.

This document is in the public domain and may be used and reprinted without special
permission. Citation of the source is appreciated.

Persons using assistive technology may not be able to fully access information in this report. For
assistance contact [email protected].

None of the investigators has any affiliations or financial involvement that conflicts with the
material presented in this report.

Suggested citation: Jonas DE, Garbutt JC, Brown JM, Amick HR, Brownley KA, Council CL,
Viera AJ, Wilkins TM, Schwartz CJ, Richmond ER, Yeatts J, Swinson Evans T, Wood SD,
Harris RP. Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol
Misuse. Comparative Effectiveness Review No. 64. (Prepared by the RTI International–
University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-
10056-I.) AHRQ Publication No. 12-EHC055-EF. Rockville, MD: Agency for Healthcare
Research and Quality. July 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

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Preface
The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health
Care Program as part of its mission to organize knowledge and make it available to inform
decisions about health care. As part of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Congress directed AHRQ to conduct and support research on the
comparative outcomes, clinical effectiveness, and appropriateness of pharmaceuticals, devices,
and health care services to meet the needs of Medicare, Medicaid, and the Children’s Health
Insurance Program (CHIP).
AHRQ has an established network of Evidence-based Practice Centers (EPCs) that produce
Evidence Reports/Technology Assessments to assist public- and private-sector organizations in
their efforts to improve the quality of health care. The EPCs now lend their expertise to the
Effective Health Care Program by conducting comparative effectiveness reviews (CERs) of
medications, devices, and other relevant interventions, including strategies for how these items
and services can best be organized, managed, and delivered.
Systematic reviews are the building blocks underlying evidence-based practice; they focus
attention on the strength and limits of evidence from research studies about the effectiveness and
safety of a clinical intervention. In the context of developing recommendations for practice,
systematic reviews are useful because they define the strengths and limits of the evidence,
clarifying whether assertions about the value of the intervention are based on strong evidence
from clinical studies. For more information about systematic reviews, see
www.effectivehealthcare.ahrq.gov/reference/purpose.cfm.
AHRQ expects that CERs will be helpful to health plans, providers, purchasers, government
programs, and the health care system as a whole. In addition, AHRQ is committed to presenting
information in different formats so that consumers who make decisions about their own and their
family’s health can benefit from the evidence.
Transparency and stakeholder input are essential to the Effective Health Care Program.
Please visit the Web site (www.effectivehealthcare.ahrq.gov) to see draft research questions and
reports or to join an email list to learn about new program products and opportunities for input.
Comparative Effectiveness Reviews will be updated regularly.
We welcome comments on this CER. They may be sent by mail to the Task Order Officer
named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD
20850, or by email to [email protected].

Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H.
Director Director, Center for Outcomes and Evidence
Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

Stephanie Chang, M.D., M.P.H. Jennifer Croswell, M.D., M.P.H.
Director Task Order Officer
Evidence-based Practice Program Center for Primary Care, Prevention, and
Center for Outcomes and Evidence Clinical Partnerships
Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

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Acknowledgments
We gratefully acknowledge the continuing support of our AHRQ Task Order Officer,
Jennifer M. Croswell, M.D., M.P.H., and the support of our former AHRQ Task Order Officer,
Sonia Tyutyulkova, M.D., Ph.D. We extend our appreciation to our Key Informants and
members of our Technical Expert Panel (listed below), all of whom provided thoughtful advice
and input during our research process.
The investigators deeply appreciate the considerable support, commitment, and contributions
of the EPC team staff at RTI International and the University of North Carolina at Chapel Hill.
We express our gratitude to the following individuals for their contributions to this project: Carol
Woodell, B.S.P.H., our Project Manager; Meera Viswanathan, Ph.D., Director of the RTI-UNC
EPC; Timothy S. Carey, M.D., M.P.H, Director of the Cecil G. Sheps Center for Health Services
Research at UNC; Megan Van Noord, M.S.L.S., our EPC Librarian; Carol Offen, editor, and
Loraine Monroe, our EPC publications specialist.
Key Informants
Key Informants are the end users of research, including patients and caregivers, practicing
clinicians, relevant professional and consumer organizations, purchasers of health care, and
others with experience in making health care decisions. Within the EPC program, the Key
Informant role is to provide input into identifying the Key Questions for research that will inform
health care decisions. The EPC solicits input from Key Informants when developing questions
for systematic review or when identifying high-priority research gaps and needed new research.
Key Informants are not involved in analyzing the evidence or writing the report and have not
reviewed the report, except as given the opportunity to do so through the peer or public review
mechanism.
Key Informants must disclose any financial conflicts of interest greater than $10,000 and any
other relevant business or professional conflicts of interest. Because of their role as end users,
individuals are invited to serve as Key Informants and those who present with potential conflicts
may be retained. The Task Order Officer and the EPC work to balance, manage, or mitigate any
potential conflicts of interest identified.

David Boyd, M.D.C.M., F.A.C.S. Shelly Greenfield, M.D., M.P.H.
Indian Health Service Harvard University
Rockville, MD Cambridge, MA
No potential conflict of interest reported. No potential conflict of interest reported.

Susan Curry, Ph.D.* Joy Melnikow, M.D., M.P.H.*
University of Iowa University of California at Davis
Iowa City, IA Davis, CA
No potential conflict of interest reported. No potential conflict of interest reported.

Michael Fleming, M.D., M.P.H.
Northwestern University
Evanston, IL
No potential conflict of interest reported.

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Richard Saitz, M.D., M.P.H. Evelyn Whitlock, M.D., M.P.H.
Boston University Oregon Evidence-based Practice Center
Boston, MA Portland, OR
Dr. Saitz coined the term “unhealthy alcohol No potential conflict of interest reported.
use” as a way to describe the spectrum of
alcohol problems, in an article in the New
England Journal of Medicine.

* Member of the U.S. Preventive Services Task Force
Technical Expert Panel
Technical Experts comprise a multidisciplinary group of clinical, content, and methodologic
experts who provide input in defining populations, interventions, comparisons, or outcomes as
well as identifying particular studies or databases to search. They are selected to provide broad
expertise and perspectives specific to the topic under development. Divergent and conflicted
opinions are common and perceived as healthy scientific discourse that results in a thoughtful,
relevant systematic review. Therefore, study questions, design, and/or methodological
approaches do not necessarily represent the views of individual technical and content experts.
Technical Experts provide information to the EPC to identify literature search strategies and
recommend approaches to specific issues as requested by the EPC. Technical Experts do not do
analysis of any kind nor contribute to the writing of the report and have not reviewed the report,
except as given the opportunity to do so through the peer or public review mechanism
Technical Experts must disclose any financial conflicts of interest greater than $10,000 and
any other relevant business or professional conflicts of interest. Because of their unique clinical
or content expertise, individuals are invited to serve as Technical Experts, and those who present
with potential conflicts may be retained. The Task Order Officer and the EPC work to balance,
manage, or mitigate any potential conflicts of interest identified.

David Boyd, M.D.C.M., F.A.C.S. Shelly Greenfield, M.D., M.P.H.
Indian Health Service Harvard University
Rockville, MD Cambridge, MA
No potential conflict of interest reported. No potential conflict of interest reported.

Susan Curry, Ph.D.* Joy Melnikow, M.D., M.P.H.*
University of Iowa University of California at Davis
Iowa City, IA Davis, CA
No potential conflict of interest reported. No potential conflict of interest reported.

Michael Fleming, M.D., M.P.H. Richard Saitz, M.D., M.P.H.
Northwestern University Boston University
Evanston, IL Boston, MA
No potential conflict of interest reported. Dr. Saitz coined the term “unhealthy alcohol
use” as a way to describe the spectrum of
alcohol problems, in an article in the New
England Journal of Medicine.

v
Evelyn Whitlock, M.D., M.P.H.
Oregon Evidence-based Practice Center
Portland, OR
No potential conflict of interest reported.

* Member of the U.S. Preventive Services Task Force
Peer Reviewers
Peer Reviewers are invited to provide written comments on the draft report based on their
clinical, content, or methodologic expertise. Peer review comments on the preliminary draft of
the report are considered by the EPC in preparation of the final draft of the report. Peer
Reviewers do not participate in writing or editing of the final report or other products. The
synthesis of the scientific literature presented in the final report does not necessarily represent the
views of individual reviewers. The dispositions of the peer review comments are documented
and will, for CERs and Technical briefs, be published 3 months after the publication of the
Evidence Report.
Potential reviewers must disclose any financial conflicts of interest greater than $10,000 and
any other relevant business or professional conflicts of interest. Invited Peer Reviewers may not
have any financial conflict of interest greater than $10,000. Peer Reviewers who disclose
potential business or professional conflicts of interest may submit comments on draft reports
through the public comment mechanism.

Susan Curry, Ph.D.* Jennifer Mertens, Ph.D.
University of Iowa Kaiser Permanente Northern California
Iowa City, IA Division of Research
Oakland, CA
John Higgins-Biddle, Ph.D.
University of Connecticut (ret.) Richard Saitz, M.D., M.P.H.
Bethany, CT Boston University
Boston, MA
Stephen Holt, M.D., M.S.
Yale University John B. Saunders, M.D., F.R.A.C.P.
New Haven CT University of Queensland; Prince Charles
Hospital; and Royal Brisbane Hospital
Bonnie McRee, M.P.H. Queensland, Australia
University of Connecticut
Farmington, CT

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Screening, Behavioral Counseling, and Referral in
Primary Care to Reduce Alcohol Misuse
Structured Abstract
Objectives. To assess the effectiveness of screening followed by behavioral counseling for
adolescents and adults with alcohol misuse in primary care settings.

Data Sources. MEDLINE®, Embase®, the Cochrane Library, CINAHL®, PsycINFO®.
Additional studies were identified from reference lists and technical experts.

Review Methods. Two people independently selected, extracted data from, and rated the quality
of relevant trials and systematic reviews. Quantitative analyses were conducted for outcomes
when feasible and used subgroup analyses to explore whether results differed by intensity, sex,
country, person delivering the counseling, or setting. Two reviewers graded the strength of
evidence (SOE).

Results. A total of 23 trials and six systematic reviews were included. The trials generally
enrolled subjects with risky/hazardous drinking, usually excluding those with alcohol
dependence. Among adults receiving interventions, consumption decreased by 3.6 drinks per
week (weighted mean difference [WMD], 3.6, 95% confidence interval [CI], 2.4 to 4.8), 12
percent fewer subjects reported heavy drinking episodes (risk difference 0.12, 95% CI, 0.07 to
0.16), and 11 percent more subjects reported drinking beneath recommended limits (risk
difference, 0.11, 95% CI, 0.08 to 0.13) over 12 months compared with controls (moderate SOE).
Interventions improved some utilization outcomes (e.g., hospital days and costs: low SOE). For
most health outcomes, available evidence either demonstrated no difference between
interventions and controls (e.g., mortality: low SOE) or was insufficient to draw conclusions
(e.g., accidents, injuries, alcohol-related liver problems: insufficient SOE). The best evidence of
effectiveness is for brief (generally, 10 to 15 minutes) multicontact interventions.
For older adults, trials provided evidence of effectiveness, but effect sizes were smaller than
for all adults. Trials enrolling college students provided evidence of effectiveness for reducing
consumption and heavy drinking episodes (moderate SOE) and some accident, utilization, and
academic outcomes (low, low, and moderate SOE, respectively). Studies in adults found benefits
lasting several years; for college students, some benefits found at 6 months were no longer
significantly different for intervention versus control groups at 12 months. The one study
enrolling pregnant women did not find a significant difference for reduction in consumption.
Evidence was insufficient for adolescent populations.
No studies randomized subjects, practices, or providers to screening and a comparator, and
none of the included studies reported followup with referrals as an outcome.

Conclusions. Behavioral counseling interventions improve behavioral outcomes for adults with
risky/hazardous drinking. For most health outcomes, available evidence either found no
difference between interventions and controls or was insufficient to draw conclusions. The best
evidence of effectiveness is for brief multicontact interventions.

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Contents
Executive Summary .................................................................................................................ES-1
Introduction ....................................................................................................................................1
Screening and Behavioral Counseling ...................................................................................... 3
Prior U.S. Preventive Services Task Force Recommendations ................................................ 4
Current Practice ........................................................................................................................ 4
Scope and Key Questions ......................................................................................................... 5
Methods ...........................................................................................................................................7
Topic Development and Refinement ........................................................................................ 7
Analytic Framework ................................................................................................................. 7
Literature Search ....................................................................................................................... 8
Study Selection ....................................................................................................................... 10
Data Extraction and Data Management .................................................................................. 12
Quality Assessment ................................................................................................................. 13
Data Synthesis ......................................................................................................................... 13
Grading Strength of Evidence ................................................................................................. 14
Applicability Assessment........................................................................................................ 15
Peer Review and Public Commentary .................................................................................... 15
Results ...........................................................................................................................................16
Introduction ............................................................................................................................. 16
Key Question 1. What is the direct evidence that screening for alcohol misuse followed
by a behavioral counseling intervention, with or without referral, leads to reduced
morbidity, reduced mortality, or changes in other long-term outcomes? ......................... 17
Summary of Findings .............................................................................................................. 17
Morbidity, Mortality, Health Care Utilization, Sick Days, Costs, Legal Issues,
Employment Stability, and Quality of Life................................................................. 17
Key Question 2: How do specific screening modalities compare with one another for
detecting alcohol misuse? ................................................................................................. 17
Summary of Findings .............................................................................................................. 18
Adults ................................................................................................................................ 18
Young Adults and College Students ................................................................................. 18
Pregnant Women ............................................................................................................... 18
Adolescents ....................................................................................................................... 18
Detailed Assessment ............................................................................................................... 19
Screening for Alcohol Misuse (The Full Spectrum) ......................................................... 20
Screening for Risky/Hazardous Drinking ......................................................................... 22
Screening for Abuse/Dependence ..................................................................................... 23
Instrument Burden ............................................................................................................ 26
Key Question 3. What adverse effects are associated with screening for alcohol
misuse and screening-related assessment? ........................................................................ 26
Summary of Findings .............................................................................................................. 26
Adverse Effects ................................................................................................................. 26
Key Question 4a. How do behavioral counseling interventions, with or without referral,
compare with usual care for improving intermediate outcomes for people with
alcohol misuse as identified by screening? ....................................................................... 27
Summary of Findings .............................................................................................................. 27
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Adults ................................................................................................................................ 27
Older Adults ...................................................................................................................... 29
Young Adults and College Students ................................................................................. 29
Pregnant Women ............................................................................................................... 29
Evidence in Adults .................................................................................................................. 29
Characteristics of Included Studies ................................................................................... 29
Alcohol Use, Number of Drinks ....................................................................................... 35
Heavy Drinking Episodes ................................................................................................. 37
Recommended Drinking Limits Achieved ....................................................................... 39
Followup With Referrals................................................................................................... 39
Abstinence......................................................................................................................... 40
Evidence in Older Adults ........................................................................................................ 40
Alcohol Use, Number of Drinks ....................................................................................... 42
Heavy Drinking Episodes ................................................................................................. 42
Recommended Drinking Limits Achieved ....................................................................... 42
Followup With Referrals................................................................................................... 42
Abstinence......................................................................................................................... 43
Evidence in Young Adults or College Students ..................................................................... 43
Alcohol Use, Number of Drinks ....................................................................................... 45
Heavy Drinking Episodes ................................................................................................. 46
Recommended Drinking Limits Achieved ....................................................................... 46
Followup With Referrals................................................................................................... 46
Abstinence......................................................................................................................... 46
Evidence in Pregnant Women ................................................................................................. 46
Alcohol Use, Number of Drinks ....................................................................................... 47
Heavy Drinking Episodes ................................................................................................. 47
Recommended Drinking Limits Achieved ....................................................................... 48
Followup With Referrals................................................................................................... 48
Abstinence......................................................................................................................... 48
Applicability ........................................................................................................................... 48
Key Question 4b. How do specific behavioral counseling approaches, with or without
referral, compare with one another for improving intermediate outcomes for people
with alcohol misuse as identified by screening? ............................................................... 48
Summary of Findings .............................................................................................................. 49
Adults ................................................................................................................................ 49
Young Adults and College Students ................................................................................. 49
Evidence in Adults .................................................................................................................. 49
Characteristics of Included Studies ................................................................................... 49
Intermediate Outcomes ..................................................................................................... 52
Evidence in Older Adults ........................................................................................................ 54
Evidence in Young Adults or College Students ..................................................................... 54
Intermediate Outcomes ..................................................................................................... 55
Evidence in Pregnant Women ................................................................................................. 55
Applicability ........................................................................................................................... 55
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