Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Brief interventions reduce alcohol consumption in men with drinking problems

ACP J Club. 1995 July-Aug;123:13. doi:10.7326/ACPJC-1995-123-1-013


Source Citation

Kahan M, Wilson L, Becker L. Effectiveness of physician-based interventions with problem drinkers: a review. Can Med Assoc J. 1995 Mar 15;152:851-9.


Abstract

Objective

To determine whether brief, physician-initiated interventions to counsel adults with drinking problems will reduce alcohol consumption.

Data Sources

Studies were identified through MEDLINE from 1966 on and EMBASE from 1972 on using the index terms problem, controlled, responsible, moderate, risk, drink, advice, physician, nurse, or general practitioner, and all terms starting with random. 43 studies were identified through EMBASE and 112 through MEDLINE. Bibliographies of relevant papers were checked.

Study Selection

Studies selected were randomized controlled trials of physician interventions designed to reduce alcohol consumption by adults with drinking problems. Trials that were set in alcohol treatment clinics, that studied alcohol-dependent populations, or that evaluated only nonphysician interventions were excluded.

Data Extraction

Trials were rated for quality (validity and generalizability) using structured scales. Numbers and sex of participants, type of setting (primary care, specialist clinic, hospital, or population-based), duration of trial, intervener (generalist or specialist, with or without nonphysician help), and outcomes (change in weekly alcohol intake, change from heavy to moderate drinking, change in serum gamma-glutamyltransferase [GGT] levels, and morbidity). Trial data were not combined.

Main Results

11 studies of 4048 participants (≥ 75% men) were included. 9 studies had follow-up < 90% and 5 had follow-up < 80%. Training sessions for physicians were < 1 hour; time spent with patients was < 30 minutes in the 3 studies in which time spent with patients was described. 5 of 9 studies in men showed a decrease in the number of drinks/wk (range, 5 to 20/wk), and 3 of 5 studies showed an increase in the proportion of men who decreased their consumption to moderate levels (range 7% to 18.2%). 4 of 8 studies showed reductions in GGT levels. 4 studies reported results for women. 1 study showed decreased consumption of alcohol and a measurable shift from heavy to moderate drinking. 3 of the 4 studies that were ranked highest in quality showed modest decreases in weekly alcohol intake (5 to 7 drinks/wk).

Conclusions

Brief interventions given by physicians to men with drinking problems are effective in reducing alcohol consumption. The data on women and on alcohol-related morbidity are more equivocal.

Source of funding: Not stated.

For article reprint: Dr. M. Kahan, Addiction Research Foundation, 33 Russell Street, Toronto, Ontario M5S 2S1. FAX 416-595-6617.


Commentary

A population-based approach to decreasing alcohol-related morbidity has increasingly grown out of the acknowledgment that far more may be gained from strategies that affect the greater morbidity associated with the broad base of problem drinkers than from the traditional disease-based approach, which attempts intervention with only the smaller number of persons considered alcohol-dependent (1, 2). Evidence that simple office-based counseling is effective, therefore, would be of considerable public health value.

Using semi-quantitative methods, Kahan and colleagues reviewed a decade of published randomized trials to assess these brief, physician-led advice interventions, and they concluded that these interventions are modestly effective in reducing alcohol intake. The authors provide a rigorous assessment of trial design features, and certain caveats deserve emphasis. Almost uniformly, for example, problem drinkers were diagnosed not by their clinicians but by special evaluators, who then recruited patients into the studies and scheduled the physician advice sessions. As a result, the ability of practicing physicians to handle initial diagnostic and motivational issues was not directly tested.

Additionally, many patients needed to be screened so that patients could be diagnosed and recruited. Enrolled problem drinkers, therefore, were likely to be more compliant and motivated than the average. Finally, outcome measurements relied primarily on self-reporting by patients, although some attempts at cross-checking or the use of surrogate markers were made. As such, the modest outcomes noted (5 to 7 fewer drinks/wk in the higher-quality studies) may overestimate the effect that might be seen in the average practice setting.

Does the noted modest reduction in alcohol intake translate into clinically relevant reductions in alcohol-related morbidity? Unfortunately, neither this nor other recent reviews (3, 4) provide a clear answer to this important question. Without this information, many physicians will not be persuaded to use these interventions.

Barry Rinker, MD, MS
Temple University School of Medicine Philadelphia, Pennsylvania