effective and cost-effective measures to reduce alcohol...
TRANSCRIPT
Making it work together
Effective and Cost-Effective Measures to Reduce
Alcohol Misuse in Scotland
EFFECTIVE AND COST-EFFECTIVE MEASURES TOREDUCE ALCOHOL MISUSE IN SCOTLAND: A
LITERATURE REVIEW
Anne Ludbrook1, Christine Godfrey2, Laura Wyness1, Steve Parrott2, SallyHaw3, Moira Napper1 and Edwin van Teijlingen4
Health Economics Research Unit1
University of York2, Health Education Board Scotland3, University ofAberdeen4
CONTENTS
EXECUTIVE SUMMARY 1
Aim of the Study 1Methods 1Effectiveness review - Main findings 1Cost-Effectiveness review - Main findings 4Conclusions 5
CHAPTER ONE INTRODUCTION 9
Summary 9Background 9Aims 9Structure of the report 10
CHAPTER TWO REVIEW OF EFFECTIVENESS REVIEWS: METHODS 11
Summary 11Introduction 11Methods 11
CHAPTER THREE REVIEW OF COST-EFFECTIVENESS STUDIES: METHODS 15
Summary 15Introduction 15Methods 15
CHAPTER FOUR POLICY AND LEGISLATION 20
Summary 20Introduction 20Fiscal policy 21Drink drive legislation 22Licensing 23Advertising controls 25Further research 25
CHAPTER FIVE ENFORCEMENT 31
Summary 31Introduction 31Legal drinking age 31Driving related 32Cost-effectiveness 34Further research 35
CHAPTER SIX PREVENTION 40
Summary 40Introduction 40School-based interventions 40Other health promotion interventions 42Cost-effectiveness 44Further research 45
CHAPTER SEVEN SCREENING AND DETECTION 57
Summary 57Introduction 57Screening questionnaires 57Laboratory tests 59Cost-effectiveness 60Further research 61
CHAPTER EIGHT BRIEF INTERVENTIONS 65
Summary 65Introduction 65Effectiveness of brief interventions 65The Cost-Effectiveness of Brief Interventions 68Modelling of results for Scotland 73Further research 75
CHAPTER NINE DETOXIFICATION 85
Summary 85Introduction 85Effectiveness of detoxification 85Cost-effectiveness 87Further research 88
CHAPTER TEN RELAPSE PREVENTION 94
Summary 94Introduction 94Effectiveness of relapse prevention 94Cost-effectiveness 98Modelling of results for Scotland 104Further research 106
CHAPTER ELEVEN OTHER ISSUES 124
Summary 124Introduction 124Effectiveness studies 124Cost-effectiveness 127
CHAPTER TWELVE EVALUATING INTERVENTIONS IN SCOTLAND 136
Summary 136Introduction 136Evaluations in Scotland 136Critical appraisal 140Evaluation guidelines 141Accessibility of findings 142Conclusions 142
CHAPTER THIRTEEN CONCLUSIONS AND RECOMMENDATIONS 143
Introduction 143Review conclusions 143Implementation issues 147Recommendations 152
REFERENCES 151
ANNEX ONE SEARCH STRATEGIES 163
Effectiveness reviews 163Cost-effectiveness review 170
ANNEX TWO STUDIES EXCLUDED FROM EFFECTIVENESS REVIEW 172
1
EXECUTIVE SUMMARY
AIM OF THE STUDY
0.1 The aim of this study is to review evidence on the effectiveness and cost-effectivenessof interventions aimed at reducing alcohol misuse.
METHODS
Effectiveness Literature
0.2 This study presents a review of existing reviews of the effectiveness literature. Thisreflects the sheer volume of literature available and the short time-scale available for thestudy. A comprehensive and systematic search of electronic databases has been undertaken toidentify all relevant reviews. The quality of the reviews has been assessed using variouscriteria ( e.g. whether a systematic search had been undertaken, whether explicit inclusionand exclusion criteria had been employed and whether the review authors had carried out anassessment of the quality of the studies).
0.3 While the effectiveness reviews, and the studies that they report, have used a varietyof different outcome measures, most have failed to report health outcomes. This studypresents an overview of the outcome measures that have been reported (by type ofintervention) and describes the statistical methods used in reporting and summarising resultswithin the reviews.
Cost –Effectiveness Literature
0.4 A search of electronic databases for the period 1990-2001 has been conducted for thereview of cost-effectiveness literature. The cost-effectiveness literature is smaller than theeffectiveness literature and of variable quality. All economic evaluations have been included,even if they are incomplete in their coverage of costs or benefits. The studies identified havebeen quality assessed using a standard checklist.
0.5 The basic methods of cost-effectiveness analysis are explained and the potential costsand consequences to be considered are summarised. A description is also given of thedifferent forms of economic evaluation; cost-offset studies, cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis.
EFFECTIVENESS REVIEW - MAIN FINDINGS
0.6 There are seven broad categories of interventions. The main findings presented in theliterature are summarised below by type of intervention.
2
Policy and legislative interventions
0.7 There is good and consistent evidence that fiscal policy (taxation) is effective inreducing total alcohol consumption, although estimates of the size of the effect are variable.What is clear is that fiscal policy affects all drinkers, not just problem drinkers, in terms of thehigher prices to be paid for alcohol. Evidence suggests that the alcohol consumption of theheaviest 10% of drinkers is not responsive to price increases but problem drinkers below thislevel do respond. The evidence relating to under-age and youth drinking is unclear.
0.8 A range of legislation has been enacted in the US to reduce drink driving:• lower permitted blood alcohol levels for younger drivers and for personswith previous convictions for drink driving;• reductions in permitted alcohol levels for all drivers;• additional sanctions for drink driving, such as mandatory licencesuspension and ignition interlock devices.
Inter-state comparisons and general trends suggest that this legislative action has beensuccessful. However, the results may not translate directly to the UK. Trends in total alcoholconsumption have also been falling in the US and this may reflect a different cultural attitudetowards both drinking and drink driving. Reductions in permitted blood alcohol levels for alldrivers took the level down to the current UK level. The impact of reductions below thislevel may be less.
0.9 Evidence relating to licensing controls is mixed. Some studies from other countrieshave suggested that longer licensing hours increase alcohol related problems but UK evidenceis unclear. There is some evidence from the US and other countries that higher outlet densityis associated with higher sales and increased fatal crashes but again the UK evidence ismixed. The type of outlet is also a relevant factor. There is mixed evidence about the impactof outlet type on alcohol-related problems but some evidence of factors that reduce thelikelihood of sales to minors. In the US, there is some evidence that raising the legal drinkingage to 21 has reduced alcohol related crashes and injuries and may reduce consumption.However, these results may not transfer to a UK setting because of different attitudes todrinking amongst young people in the UK.
0.10 Studies of advertising and alcohol consumption over time have failed to find asignificant association, although this may be due to the limited variation in advertisingexpenditure. Studies of advertising bans across countries have found an effect but this maybe due to countries with low consumption being more likely to ban advertising. There isstronger evidence to support the effect of advertising on children.
Enforcement
0.11 The best evidence of effectiveness relates to random breath testing, which has beenshown to be effective in both Australia and the US. The evidence relating to the effectivenessof mandatory licence suspension is mixed and ignition interlock devices appear to beeffective but only while fitted.
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Prevention
0.12 Most of the effectiveness evidence relates to school-based interventions and providesrelatively weak evidence of effects on knowledge rather than behaviour. These studies arenot of particularly good quality; in particular, the studies have poor controls. Characteristicsof programmes which appear to contribute to success are interactive delivery, parental orcommunity involvement and peer involvement.
0.13 Mass media campaigns relating to alcohol, tobacco or illicit drugs show some effectson knowledge and attitudes but little on behaviour. Evaluation of three communityprevention programmes provided mixed results.
Screening and detection
0.14 Although a number of screening questionnaires are available to detect alcohol misuse,their performance is extremely variable. Some are better at detecting certain levels of alcoholmisuse than others. For general screening purposes, AUDIT is more effective in detecting atrisk, hazardous or harmful drinking whilst CAGE is superior for detecting alcohol abuse anddependency. These two tests perform better than other screening tests. T-ACE and TWEAKare more sensitive and specific than CAGE for screening pregnant women. MAST may beuseful in psychiatric settings. Laboratory tests do not perform well as screening instruments.
Brief interventions
0.15 The majority of studies have shown brief interventions to be effective in changingdrinking behaviour and reducing alcohol consumption for at least 12 months in patients whoare not alcohol dependent. The evidence from these research studies is consistent but thereare concerns about generalising these results outwith the research setting.
Detoxification
0.16 The literature supports the use of benzodiazepines as the first choice therapy on thebasis of safety and effectiveness but the quality of studies is not very high. Outpatienttreatment is safe and effective for patients with mild to moderate symptoms. Where inpatienttreatment is required, longer stays have not been demonstrated to increase effectiveness.
Relapse prevention
0.17 Despite a lack of randomised-controlled trials, psychosocial interventions areconsidered to be effective. In a large US study, the total percentage achieving abstinence orcontrolled drinking was 56% to 60% compared with an estimated spontaneous remission rateof 33%. Pharmacological treatments are effective as adjuncts to psychosocial interventions.Both Naltrexone and Acamprosate have been shown to delay a return to drinking. Co-existing psychiatric problems should be appropriately treated.
4
COST-EFFECTIVENESS REVIEW - MAIN FINDINGS
Enforcement
0.18 A modelling study of the costs and benefits of random breath testing using US dataprovides evidence to suggest that this intervention is cost-effective. A cost-benefit study of aserver training programme in the US showed benefits in excess of costs. As with all studiesbased on US cost data, these results are not directly transferable to a UK setting. Avoided useof health care services forms a large part of the benefits and service usage in the US is likelyto higher in both volume and price.
Prevention
0.19 A cost-effectiveness study of implementing office-based preventive services foradolescents in the US suggests that this is not cost-effective. The cost of preventing a deathdue to a motor vehicle crash was $12 million (£8.17 million). This compares withDepartment of Transport estimates of the value for preventing a fatality of approximately £1million. An Australian study of the cost-effectiveness of thiamine-supplementationalternatives in preventing the Wernicke-Korsakoff syndrome found that the most cost-effective strategy for preventing WK encephalopathy was fortifying full strength beer, ratherthan wine or bread-making flour. The cost per case averted was AUS$662 (£235).
Screening and detection
0.20 There is little evidence about the cost-effectiveness of screening. Telemarketing hasbeen shown to be a cost-effective strategy for promoting the Drink-less screening and briefintervention package to GPs in Australia. A study of alternative staff carrying out screeningin a UK general hospital, concluded that a specialist worker was most cost-effective but notedthat nurses could be used more flexibly.
Brief interventions
0.21 Three economic studies have shown brief interventions to be relatively cost-effective,due to fairly high levels of effectiveness and low costs. Modelling results using UK cost datasuggests that the cost per life saved is in the range £1446-£2628 if no savings in resource useare taken into account. If resource savings are considered then the benefits exceed the costsof the intervention.
Detoxification
0.22 Economic studies have shown home detoxification and outpatient detoxification to becost-effective but these were small and rather limited studies.
5
Relapse prevention
0.23 The health care cost savings for psychosocial interventions are dependent upon thekey patient characteristics of alcohol dependence, psychiatric severity and the level ofnetwork support for drinking. Cost-effectiveness can be improved by matching patients totreatment. Two studies have modelled the cost-effectiveness of Acamprosate. In a Belgianstudy, a cost saving to the health care provider was found of 22,000 BEF (£337) per patientover 24 months. The results were sensitive to the probability of relapse and under differentconditions there may not be a cost saving. A German study found an overall cost saving tosociety of DM2,602 (£822) per additional abstinent patient. Modelling the results using UKdata confirms that a resource saving of over £600 per patient will result.
0.24 Two studies of inpatient versus outpatient care after detoxification found outpatientcare to be more cost-effective. Two small studies of behavioural marital therapy haveproduced opposite conclusions regarding cost-effectiveness.
Other issues
0.25 Some cross cutting reviews look at settings and populations rather than specificinterventions. These studies do not provide comparative effectiveness data. There are alsoreviews providing information about education and training for professional groups.
Scottish evaluations
0.26 There has been considerable activity in Scotland in implementing initiatives to reducealcohol misuse and its consequences. Some examples of the evaluation studies have beenreviewed but not all of these are focussed on effectiveness. The most useful findings reportedhere relate to brief interventions by health visitors and home detoxification services.Counselling services are clearly effective but research is required to establish whether thecurrent pattern of provision is more effective than a briefer intervention. The role ofcomplementary therapy requires larger studies to be carried out. A culture of evaluation thatis focussed on outcomes needs to be fostered at all levels from policy making to servicedelivery.
CONCLUSIONS
Summary of available evidence
0.27 The main findings from the review of the literature on effectiveness and cost-effectiveness are summarised in table 0.1. In terms of the effectiveness review, there is astrong and relevant evidence base to show that:• the use of price increases, via taxation, and brief interventions will reduce the number of
problem drinkers;• effective screening tools to detect problem drinkers are available (CAGE and AUDIT);
and
6
• detoxification services and relapse prevention, through appropriate psychosocial andpharmacological treatments, are effective.
0.28 The cost-effectiveness review found evidence to support the cost-effectiveness of:• brief interventions;• home and outpatient detoxification;• outpatient treatment for relapse prevention; and• the use of acamprosate as an adjunct treatment in relapse prevention.
Quality, coverage and relevance of the evidence
0.29 The quality of the effectiveness reviews and the underlying primary studies isvariable. The evidence base of economic studies is weak. The best evidence of effectiveness,in terms of both quality and coverage, relates to brief interventions and relapse prevention.There are a number of economic studies in these areas, of reasonable quality, but of limitedrelevance to the UK. Prevention, particularly in schools, has been widely researched but thepoor quality of many of the studies means that the evidence base remains weak. Policyevaluation is not of high quality and particularly difficult to relate to the UK.
Lessons about methods of evaluation
0.30 In order to improve the evidence base in the UK, more emphasis needs to be placed onevaluating alcohol initiatives in the UK and on modelling UK results based on internationalstudies. Evaluations should be planned at an early stage in the development of an initiativeto ensure that the data required to conduct a meaningful evaluation are available. Bettermethods of policy evaluation are required to provide robust evidence where there is no accessto random controls and these need to be developed and applied in a UK context to providerelevant information.
Implementation issues
0.31 The results of the review will have to be interpreted alongside information aboutinterventions that are already taking place in Scotland. Both the impact which interventionswill have upon strategic targets and the resources required to implement interventions, willdepend upon the extent to which they have already been deployed. The effectiveness of theseinterventions has been demonstrated in research settings and arrangements for auditing ormonitoring the effectiveness of interventions in routine practice will need to be put in place.A review of policy strategies in other countries has found that reducing alcohol consumptionin the general population or in high risk populations are equally effective in preventingalcohol related problems. The costs of the alternative strategies are not reported.
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RECOMMENDATIONS
0.32 It is recommended that the Plan for Action should support:Population measures
• the introduction of a brief intervention programme where this is not alreadyprovided; and
• the development of monitoring arrangements to assess the impact of theseinterventions.
Treatment measures• improved access to treatment and relapse prevention; and• the use of cost-effective alternatives, such as home detoxification, where
appropriate.Research measures
• the prioritisation of policy evaluation and prevention as the areas requiringmost development of the evidence base;
• better co-ordination of research effort with resources concentrated on fewerlarger studies with longer term follow up;
• better knowledge management in terms of access to relevant research results;• the fostering of an evaluation culture amongst those responsible for delivering
services, focussed on outcomes and the monitoring of effectiveness; and• guidelines for evaluation to assist in this process.
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Tab
le 0
.1Su
mm
ary
of F
indi
ngs
Eff
ecti
vene
ss e
vide
nce
supp
orts
Cos
t-ef
fect
iven
ess
evid
ence
supp
orts
Com
men
ts
Pol
icy
and
legi
slat
ion
Pri
ce in
crea
ses
via
taxa
tion
Not
hing
ha
s be
en
form
ally
eval
uate
dL
ower
pe
rmit
ted
bloo
d al
coho
lle
vels
; ra
isin
g le
gal
age
for
drin
king
;lo
wer
out
let d
ensi
ty
Evi
denc
e no
t fro
m U
K
Enf
orce
men
tR
ando
m b
reat
h te
stin
g of
dri
vers
Ran
dom
bre
ath
test
ing
of d
rive
rsU
S st
udy
impl
ies
cost
dat
a m
ay n
ot a
pply
.Se
rver
trai
ning
pro
gram
me
US
stud
y im
plie
s co
st d
ata
may
not
app
ly.
Pre
vent
ion
No
conv
inci
ng
effe
cts
have
be
ende
mon
stra
ted
on d
rink
ing
beha
viou
r.E
vide
nce
of e
ffec
t on
kno
wle
dge
and
attit
udes
fro
mm
ass
med
ia c
ampa
igns
. W
eak
evid
ence
of
effe
ct o
nkn
owle
dge
from
sch
ool-
base
d in
terv
enti
ons.
Thi
amin
e su
pple
men
tatio
n of
fu
llst
reng
th b
eer
to p
reve
nt W
erni
cke-
Kor
sako
ff s
yndr
ome
Aus
tral
ian
stud
y
Scre
enin
g an
d de
tect
ion
CA
GE
and
AU
DIT
as
scre
enin
g to
ols
for
gene
ral p
opul
atio
nsU
se
of
spec
iali
st
wor
kers
fo
rsc
reen
ing
in
a ge
nera
l ho
spita
lse
tting
UK
stu
dy.
Nur
sing
sta
ff w
ere
less
cos
t-ef
fect
ive
but
may
be
used
mor
e fl
exib
ly.
Bri
ef in
terv
enti
ons
Bri
ef
inte
rven
tions
in
a
rang
e of
rese
arch
set
ting
sB
rief
inte
rven
tions
No
cost
dat
a fr
om U
K s
tudi
es i
mpl
ies
cost
-off
sets
may
not
be
high
.D
etox
ific
atio
nB
enzo
diaz
epin
es
as
firs
t ch
oice
ther
apy
Hom
e an
d ou
tpat
ient
det
oxif
icat
ion
Rel
apse
pre
vent
ion
Psy
chos
ocia
l int
erve
ntio
nsO
utpa
tient
trea
tmen
tN
altr
exon
e an
d A
cam
pros
ate
asad
junc
t tre
atm
ents
Aca
mpr
osat
e as
an
ad
junc
ttr
eatm
ent
Cos
t da
ta f
rom
Bel
gium
and
Ger
man
y bu
t re
sults
conf
irm
ed w
hen
mod
elle
d w
ith U
K d
ata.
9
CHAPTER ONE INTRODUCTION
SUMMARY
This chapter:• explains the background to the commissioning of the review;• describes the aims of the review; and• sets out the structure for the rest of the report.
BACKGROUND 1.1 Alcohol misuse in Scotland is increasing. Recently published figures show thatbetween 1995 and 1998 there was an increase in alcohol consumption among women aged16-64, with the proportion exceeding recommended safe drinking limits increasing from 13%to 15%. Whilst there has been little change in drinking patterns for men aged 16-64 over thesame time period, there were increases in both alcohol consumption and the proportionexceeding recommended limits in the youngest age group, 16-24 (Scottish Executive, 2000). 1.2 The Scottish Executive has set targets for reducing alcohol misuse and has set up theScottish Advisory Committee on Alcohol Misuse (SACAM) (The Scottish Office, 1999).SACAM’s remit is “to advise the Scottish Executive on policy, priorities and strategicplanning in relation to tackling alcohol misuse in Scotland”. SACAM brings together keyinterests in health, education, social work, the police, health promotion, the voluntary sectorand representatives of the licensed trade and drinks industry. The Scottish Executive andSACAM are working together to develop a Plan for Action for Alcohol Misuse. This reporthas been commissioned by SACAM to provide information on the evidence available aboutthe effectiveness and cost-effectiveness of alternative measures to reduce alcohol misuse and,hence, to inform the Plan for Action for Alcohol Misuse.
AIMS 1.3 The aim of this study was to review evidence on the effectiveness and cost-effectiveness of interventions aimed at reducing alcohol misuse. The specification requiredthat the review would:
• identify measures that have been evaluated in terms of their effectiveness and cost-effectiveness;
• categorise these by type of intervention;• identify whether the interventions were aimed at particular sub-groups within the
population;• assess the quality of the studies;• summarise the conclusions to be drawn from the available evidence;• identify the main gaps in the evidence base; and• provide advice on the lessons to be learned about methods of evaluation in this
area.
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STRUCTURE OF THE REPORT 1.4 The following two chapters provide details of the methods used in the two reviewscarried out to meet the aims of the study. Chapter 2 concerns the review of effectivenessreviews and chapter 3 deals with the review of cost-effectiveness literature. The mainfindings of the two reviews are then reported by type of intervention in chapters 4 - 10:
Chapter 4 Policy and Legislation Chapter 5 Enforcement Chapter 6 Prevention Chapter 7 Screening and Detection Chapter 8 Brief Interventions Chapter 9 Detoxification Chapter 10 Relapse Prevention
1.5 Chapter 11 of the report presents further results from reviews that dealt with particularpopulation groups, providers or settings rather than types of intervention. This chapter alsocovers issues such as the educational needs of providers. Chapter 12 reviews some examplesof evaluations carried out in Scotland. Finally, chapter 13 summarises the main findings andmakes recommendations.
Definition of Intervention Categories 1.6 Tackling alcohol misuse clearly encompasses all the areas of activity set out above.Categorising interventions to particular headings can be difficult because there are a numberof grey areas and overlaps between the interventions. For clarification, the approach used inthis report is as follows:
policy and legislation refers to measures such as tax policy, advertising controls andlegislation on matters such as licensing, legal drinking age and drink drivingregulations. enforcement deals with specific interventions such as random breath testing that areundertaken to increase compliance with legislation. prevention covers all broad based health education and health promotion interventions screening and detection examines the evaluation of screening instruments anddetection strategies. The use of screening as an integral part of brief interventions, forexample, is not included. brief interventions are the planned or opportunistic counselling of heavy or problemdrinkers about their drinking behaviour. detoxification is the acute treatment of alcohol withdrawal. relapse prevention is concerned with maintaining patients as either abstinent orcontrolled drinkers after detoxification.
1.7 Where appropriate, further sub-headings have been used within each chapter. Withineach chapter, results are presented in terms of overall conclusions about the effectiveness ofthe intervention, the population groups covered by the effectiveness evidence, the setting forthe intervention (where appropriate), the type of provider (where appropriate) and commentson the quality and relevance of the effectiveness evidence. The relevant cost-effectivenessevidence is presented next and the chapters conclude with a discussion of the main gaps in theevidence requiring further research.
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CHAPTER TWO REVIEW OF EFFECTIVENESS REVIEWS: METHODS
SUMMARY This chapter concerns the methods used in the review of effectiveness reviews. It covers:• the reasons for basing the review on existing reviews;• the search strategy employed;• issues concerning quality assessment;• the types of effectiveness measures used in studies; and• introduces and explains some of the relevant statistical methods.
INTRODUCTION 2.1 There is an extensive literature, of variable quality, on the effectiveness ofinterventions to reduce alcohol misuse. A number of reviews of the effectiveness ofinterventions have been carried out. These include some good quality meta-analyses ofevidence from well-conducted trials of treatment interventions and some more generalreviews from authoritative sources. Given the volume of literature, it would not have beenpossible to review all of the individual studies within the alcohol misuse area in the timeavailable for the study. It was therefore decided to base this part of the study on a review ofexisting reviews of effectiveness.
METHODS
Search Strategy 2.2 The search of electronic databases included MEDLINE, EMBASE, HealthSTAR, ISIDatabases (Science & Social Citation Indexes), PsychINFO (on line version of PsychLIT),International Bibliography of the Social Sciences (IBSS), Cumulative Index of Nursing &Allied Health Literature (CINAHL), International Pharmaceutical Abstracts, HealthManagement Information Consortium (HMIC), EconLIT, SIGLE (System for Grey Literaturein Europe) and The Cochrane Library. 2.3 Details of the search strategies used are given in Annex 1. The search for reviews inrelation to alcohol misuse used the high sensitivity, low precision strategy developed by theNHS CRD for the identification of reviews and meta-analysis (Boynton et al, 1998). Thisinvolves identifying a wide range of references that can be checked against inclusion criteria,rather than using a strategy that is more precise in the references included but risks excludingrelevant material. Studies were included if they had carried out a review and this includedspecific interventions.
12
2.4 In addition, some studies were reviewed which dealt with issues such as provider rolesor settings. Even if these did not report specific comparative interventions, these wereretained and reported separately. Finally, individual studies of interventions implemented inScotland, published or unpublished, were identified through direct contact with local services.These are reported as service examples rather than as evaluations. The time-scale of the studydid not permit further hand searching or follow up of references from the retrieved literature.
Quality Assessment 2.5 The gold standard for conducting systematic reviews of effectiveness in the clinicalsphere has been set by the Cochrane Collaboration. Reviews that appear in The CochraneLibrary have been conducted to rigorous standards and will identify the quality of the studiesreviewed. The review process adopted by The Cochrane Library involves, wherever possible,checking details of the original studies with the authors, rather than relying solely on theinformation reported in the published source. This would not have been feasible in the timescale available for the current review. The strict standards applied by the CochraneCollaboration, however, would have excluded a large number of reviews that may containrelevant results. 2.6 As indicated above, the search strategy was designed to identify all reviews ofinterventions to reduce alcohol misuse. The quality of the review process was assessed interms of whether the authors reported that they had:
• carried out a systematic search for literature;• applied clear inclusion and exclusion criteria; and• assessed the quality of the studies included.
Effectiveness Measures 2.7 An important omission in the majority of studies is the lack of any generic measuresof health outcome. Given the range of interventions covered by this report, this means that itwill not be possible to report uniform measures of effectiveness across all areas. Indeed,different measures of effectiveness are used within the literature on single interventions. Theoutcomes of interventions may be reported in terms of their impact on alcohol consumptionor their impact on harms associated with alcohol consumption. Changes in alcoholconsumption may be evaluated by measuring the level of consumption or the proportion ofpatients reducing consumption. Examples of some of the appropriate measures that may beused for each type of intervention are indicated in chart 2.1. 2.8 The review process must also take into account the definitions of alcohol misuse used.The targets for reducing alcohol misuse identified by the Scottish Executive are concernedwith ‘heavy drinking’ by a large proportion of the adult population. The literature on alcoholmisuse is generally concerned with ‘problem drinking’ and the reduction of harms associatedwith this. Problem drinking is variously defined; for example, as alcohol dependence,alcohol abuse (serious disturbances of normal functioning without satisfying the criteria fordependence) and hazardous use of alcohol (binge or chronic heavy drinking) (Dinh-Zarr et al,
13
2000). It will be important therefore to identify population subgroups not only indemographic terms but also in terms of their level of alcohol misuse.
Chart 2.1 Overview of measures of effectiveness
Type of intervention Measures of effectiveness Policy and legislation Population based measures of alcohol consumption.
Proportion of population exceeding recommendedlimits. Numbers of alcohol related motor accidents.
Enforcement Reduction in offences such as drink driving andunder-age sales of alcohol or their consequences
Prevention Population or individual measures depending onintervention. Changes in knowledge, attitudes andbehaviour.
Screening and detection Validity and reliability of screening instrument.Detection rates for different screening strategies.
Brief interventions Individual based measures of level of change inalcohol consumption, proportion of patients reducingalcohol consumption and abstinence rates.
Detoxification Abstinence rates or problem free drinking rates Relapse prevention Increase in length of abstinence or reduction in
alcohol consumed
Statistical methods used within reviews 2.9 Some of the reviews included in this report have simply described the results that havebeen found in the literature. In some cases, this is entirely appropriate, as the studies are notsufficiently similar for pooling of results to take place. In other cases, the reviews onlyprovide qualitative information about the studies included. Where studies have reportedstatistical summaries of the findings, reviews use different methods, some of which are easierto interpret than others, in terms of the impact of the intervention on alcohol misuse. Meta-analysis, involving the use of statistical methods to pool results from studies, is applied insome of the reviews, although it should be noted that in older studies the term meta-analysismay be used more generally to mean a summarising of findings. 2.10 A number of primary studies report results in terms of effect size. For the outcomevariable of interest, this is measured as the difference between the intervention and controlgroup means, divided by the pooled standard deviation. It measures the extent to which thedistribution of the outcome variable has been changed by the intervention. This is a validmethod for determining whether the intervention has had a statistically significant impact.However, it is not always possible to provide a meaningful interpretation of the effect sizewithout reference to the original study data. 2.11 Where reviews have carried out a quantitative analysis of such studies, the pooledresults are reported in terms of the weighted mean effect size; each effect size is weighted bythe inverse of its variance. This process gives greater weight to larger samples with moreprecise results.
14
2.12 Study results can be more easily understood when the results have been reported interms of the change in the outcome variable of interest; for example, the reduction in units ofalcohol consumed or the increase in abstinence rates. Another method of reporting results isthe odds ratio, which is the likelihood of observing an outcome for the intervention groupcompared with the comparison group. An odds ratio of 1 reflects no difference between thegroups. An odds ratio of 2 indicates the outcome is twice as likely. 2.13 The statistical significance of the findings refers to the possibility that differences inthe intervention and comparison groups are observed by chance. A result is referred to asbeing statistically significant when the probability of the result occurring by chance fallsbelow some threshold, usually 5%. Alternatively, this information can be presented in termsof a confidence interval (CI), usually 95%. This gives a range around the estimated valuewithin which the true value is expected to lie. There is only a 5% chance that the true valuelies outside a 95% CI.
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CHAPTER THREE REVIEW OF COST-EFFECTIVENESS STUDIES: METHODS
SUMMARY This chapter concerns the methods used in the review of cost-effectiveness studies. Itincludes:• a general discussion of the literature available;• the search strategy employed;• a description of the quality assessment carried out;• an explanation of the general principles of cost-effectiveness analysis, with a checklist of
relevant costs and consequences;• a discussion of the application of these general principles within the alcohol field; and• a taxonomy of types of economic analysis.
INTRODUCTION
3.1 The cost-effectiveness literature is smaller than the effectiveness literature and ofvariable quality. Several other reviews of alcohol services have been undertaken previously.Godfrey (1994) reviews the literature prior to 1994, dividing studies into cost-offset, cost-benefit and cost-effectiveness. More recently, French (2000) provides an updated review.French covers a wide range of interventions, although the categorisation of studiesdemonstrates the majority to be merely costing studies without reference to patient outcomes.In addition, French identified a number of studies relating to general substance abusetreatment, as opposed to specific alcohol treatment. A systematic review of studies publishedin the period 1990 – 2000 has been undertaken for this report. It is considered that any earlierstudies that might be identified would be of limited relevance. The search strategy is outlinedbelow.
METHODS
Search Strategy
3.2 Systematic searches of electronic databases have been undertaken to identify anystudy that has undertaken some form of economic evaluation even if this is not complete.Studies where a passing reference to costs or cost-effectiveness is given without anysupporting data have been excluded. The databases searched were Medline, Embase, DARE(B system), NHS EED (B system), HTA (B system), Ongoing Reviews d/b (T system),National Research Register, Cochrane Library, HEED, EconLit, Social Science CitationIndex, Science Citation Index, Cinahl, British Nursing Index, PsychInfo, SIGLE, HMIC,AMED, PAIS, ASSIA Plus, EconBase (WWW), and HDA Evidencebase (WWW)
16
3.3 The search for cost-effectiveness literature for the economic analysis searched 22electronic databases. The systematic search strategy is shown in Annex 1 and the databasesare shown in table 3.1. A total of 2,303 references were found. The abstracts of the articleswere checked by hand and studies with economic data were closely scrutinised. A MicrosoftAccess database was constructed to abstract data from studies including details of both costsand consequences of alcohol interventions. A key selection criterion was to limit the analysisto studies that related to specific alcohol treatments or ranges of treatments, since thesestudies would permit costs to be derived for the treatments in question.
Table 3.1 List of databases and date range searched
Database Date range searched Records in SP_alcohol.enl
Medline 1990-2000/12 224Embase 1990-2001/02 754DARE (B system) 1990-2001/05NHS EED (B system) 1990-2001/05 16HTA (B system) 1990-2001/05Ongoing Reviews d/b (T system) 1990-2001/05 3National Research Register 1990-2001 19Cochrane library 1990-2001 23HEED 1990-2001/05 137EconLit 1990-2001/03 64Social Science Citation Index 1990-2001/05 307Science Citation Index 1990-2001/05 311Cinahl 1990-2001/02 60British Nursing Index 1990-2001/02 1PsychInfo 1990-2001/03 213SIGLE 1990-2000/12 0HMIC 1990- 70AMED 1990-2000/12 1PAIS 1990-2000/07 58ASSIA Plus 1990-2000? 0EconBase (WWW) 1990- 6HDA Evidencebase (WWW) 1990- 1Total number of records 2303
Quality Assessment
3.4 All the identified studies were subject to a rigorous individual critique to assess howmuch confidence could be placed on the specific results. This involved the use of the generalchecklist devised by Drummond et al (1997). The extent to which studies had encompassedall relevant costs and consequences was reviewed using the more specific item checklistoutlined in chart 3.1.
Assessing Cost-effectiveness
3.5 Economic evaluation involves building upon effectiveness information to assess boththe costs of delivering the different policies or interventions and also assessing a wide range
17
of consequences. The steps in any economic evaluation involve identifying, measuring,valuing and then comparing the costs and consequences of two or more alternatives. Thereare a number of different variables involved in the final result and variations in results couldbe due to a number of factors. Also, local conditions can influence the value of costs andconsequences, especially between countries. This problem can be overcome if data on unitsof resource use are reported. In this case, relevant local data on costs can be applied. Whereavailable in the review, these units have been recorded in the database as well as the financialcost estimates.
3.6 The application of economic evaluation techniques also involves researchers making anumber of assumptions and, generally, individual studies undertake a range of sensitivityanalysis to test the robustness of their findings to changes in these assumptions. Synthesisingevidence on cost-effectiveness is not as straightforward as for effectiveness reviews nor arethere well-developed techniques. There do exist, however, a number of checklists to assessthe quality of individual studies.
Chart 3.1 Checklist of potential costs and consequences of alcohol interventions
COSTS
1. Direct intervention costs• Resource costs e.g. for treatment, media campaigns, passing new legislation etc• Implementation and administration, e.g. for tax, enforcement costs for legislation
2. Costs to other agencies• Social care demands from more people in treatment• Additional treatment demand from public awareness campaign, brief intervention
implementation etc.3. Costs to the individual and their families
• Direct costs of a specific policy, for example time and travel costs of treatment
CONSEQUENCES
1. Benefits to individuals and families of reduced alcohol problems• Improved quantity (less premature deaths) and quality of life• Improved social and family functioning, including reductions in alcohol related violence,
less financial problems, criminal justice involvement etc.• Improved earnings and employment
2. Resource savings• Potential fall in future health care costs• Reduction in criminal justice expenditure from less alcohol related violence, drink
driving incidents etc.• Reduced social care, housing demands etc.
3. Other value created from alcohol interventions• Increased productivity• Reductions in alcohol related accidents, fires etc and death and injury to third parties• Impact on communities from reducing street drinking and public order nuisance
4. Adverse consequences• Some policies while reducing one alcohol problem may have an impact on others, e.g.
changes in licensing laws
18
3.7 In practice there are very few good quality economic evaluations that have beenundertaken. The largest literature is for face to face treatments. It may be expected that thesestudies would be of a similar quality to those found in other health care areas. Unfortunately,many have omitted major costs or consequences. The evidence that can be drawn from suchstudies is, therefore, of a very different quality from that which can be taken from a well-conducted systematic review. In general, the lessons drawn illustrate some of the issues thatwill impact on cost-effectiveness rather than lead to any ranking between interventions.
Costs and consequences relevant to assessing the cost-effectiveness of alcoholinterventions. 3.8 Alcohol misuse impacts on the individual drinker, their families, their communitiesand the wider society. In economic terms, drinking is associated with a range of private andexternal (third party) costs. For this study we have assessed all (social) costs andconsequences where possible. Also, different policies have different resource inputs andcosts and a range of consequences. Fiscal and legislative approaches are imposed ondrinkers, not voluntarily undertaken in the same way as those seeking help through treatment.Some policies impact (and impose costs) on all drinkers whether or not they are causingproblems for themselves or others. A checklist of the cost and consequences was given inchart 3.1. 3.9 Not all interventions involve all of these costs and consequences. In particular, amedia campaign or schools education campaign may involve a high level of direct resourceinputs. However, any change in drinking patterns that resulted from any intervention wouldbe undertaken voluntarily and therefore not involve any loss in consumption benefits. Taxpolicies are not resource costly and do not involve large implementation costs but mayinvolve such lost consumption benefits. A change in legislation will involve some costs butis unlikely to be effective unless it is enforced and this can involve larger resource outlays.
A taxonomy of economic evaluations. Cost-offset studies or cost analysis. 3.10 Many economic studies in the alcohol field have restricted their attention to thequestion of whether treatment costs are offset by savings in future alcohol related medicalcare and other external costs of alcohol. The implicit alternative in such studies is thecounterfactual that the individuals concerned would not have received any specialist care.This is a very realistic alternative in many countries, for example, only 1 to 5 per cent ofdependent drinkers receive any specialist help in the UK in any one year (Godfrey, 1997).These studies, however, set a higher hurdle for alcohol treatments compared to other healthcare interventions. Also the value to the individual of treatment is excluded. Holder (1998)concludes that these studies do indicate that alcohol treatment is likely to be cost beneficial,even with limited consequences included. However, the results are influenced by the size ofsavings in treatment costs and these will tend to be much higher in the US than in the UK, asboth the volume of service use and the cost per item of service are higher.
19
Cost-effectiveness analysis.
3.11 Cost-effectiveness analysis refers strictly to evaluations where the main individualoutcome is measured in a single, specific way, for example, reduction in alcoholconsumption, abstinent days or reduction in a problem index. The approach is of less valuewhen a range of outcomes has to be considered. Direct comparisons across different studiesare only possible to the extent that the same outcome measures have been used. The term,cost-effectiveness analysis, is often used more generically in the literature to refer toeconomic evaluation. Cost-utility analysis. 3.12 Cost-utility studies have been particularly favoured in health care evaluations(Drummond et al, 1997). These studies use specific health related quality of life measures,where values exist, of the benefits perceived from individuals moving from one health state toanother. These data are combined with estimates of the time period for which the healthbenefits will last to give quality adjusted life years. These measures allow the comparison oflife saving with life enhancing interventions. While a number of studies are currentlyunderway using these measures alongside alcohol specific outcomes, their usefulness inevaluating alcohol interventions is unknown. Their benefit more generally is that the relativecost-effectiveness of interventions in very different areas can be compared using a measurewith clear equity weights; one QALY has the same value for all people. This contrasts to thehuman capital measure of valuing life, often used in social cost studies, where higher earnershave more value than those with low earning potential. Cost-benefit analysis. 3.13 Cost-benefit analysis refers to evaluations where all the effects are measured in moneyterms. This allows direct comparison with the costs of each intervention and the net worth ofeach of the alternatives can be estimated. Such studies are rarely carried out in full, and themethods for determining monetary values for health effects are still subject to somecontroversy.
Interpreting the available literature on cost-effectiveness. 3.14 The limited available literature has been reviewed and the results are reported withineach chapter. In addition, a commentary on the relevance of the available results to theScottish context is provided. The second stage of the economic analysis has been to use theresults of the effectiveness reviews to attempt some outline modelling for brief interventionsand relapse prevention, using Scottish costing on the resources needed for the interventionand the potential consequences. These results are reported in chapters 8 and 10.
20
CHAPTER FOUR POLICY AND LEGISLATION
SUMMARY This chapter reviews the effectiveness evidence relating to policy and legislativeinterventions. No cost-effectiveness studies were found in this area. The main findings are:• increasing the price of alcohol through taxation is effective in reducing consumption,
although the size of the effect is uncertain;• reductions in permitted blood alcohol levels for drivers have been effective in reducing
motor crashes and fatalities in the US;• evidence relating to licensing controls is unclear, particularly in the UK; and• no association has been found between advertising and alcohol consumption. The results in this chapter require to be interpreted with caution as they depend largely onstudies conducted outwith the UK. More research on the impact of UK policy and legislationis required.
INTRODUCTION 4.1 Chapters 4-10 present the findings of the effectiveness and cost-effectiveness reviewsby type of intervention, namely
• Policy and Legislation• Enforcement• Prevention• Screening and Detection• Brief Interventions• Detoxification• Relapse Prevention
This chapter concerns policy and legislative interventions that can impact on alcoholconsumption and misuse. It covers:
• fiscal policy (alcohol taxes);• drink driving controls;• licensing provisions; and• policy towards alcohol advertising.
These interventions have to be evaluated at a population level and the types of analysisemployed include looking at trends over time, comparing outcomes of interest before andafter the introduction of some change, and comparisons of different populations experiencingdifferent policy or legislative frameworks. There are no cost-effectiveness studies in theliterature covering this area, although some of the effectiveness evidence comes from othertypes of economic analysis. The studies reviewed are summarised briefly in table 4.2 at theend of the chapter.
21
FISCAL POLICY
Types of intervention 4.2 Governments can influence the price of alcohol through the level of general orspecific taxation on alcohol products. Although governments can reduce disposable incomethrough increases in income tax, this has never been considered as an intervention to reducealcohol misuse. The remainder of this section concentrates on price effects.
Evidence of effectiveness 4.3 Statistical analysis of prices and alcohol consumption over time provides evidence ofthe effect of prices on the population level of alcohol consumption. Increases in price reducealcohol consumption but estimates of the size of the effect vary considerably. Price effectsare measured in terms of the price elasticity, which relates the change in consumption to thesize of the price increase. Thus, a price elasticity of –1.0 implies that a 1% increase in pricewill produce a 1% reduction in consumption. If the absolute size of the price elasticity is lessthan 1 then any price increase will produce a less than proportional reduction in consumption.Table 4.1 summarises the available information on price elasticities. The upper part of thetable gives the number of studies that have reported results in the ranges specified and thelower part of the table gives UK Treasury estimates used to forecast tax revenue. 4.4 These estimates cover different time periods and different countries. The latest dataincluded are for 1992. Comparisons across the studies are not possible without access to theoriginal data. However, there appears to be some consistency in the finding that elasticitiesare higher for wine and spirits than for beer (NIAAA 2000; Raistrick et al 1999). The impactof tax increases on targets for the National Alcohol strategy would depend, therefore, onwhich forms of alcohol are most associated with problem drinking.
Table 4.1 Summary of price elasticity data Beer Wine Spirits Price elasticity estimates from the literature : Number of results in the range 0.0 - -0.1 3 0 0 Number of results in the range -0.11 - -0.4 11 6 4 Number of results in the range -0.41 - -0.7 2 1 7 Number of results in the range -0.71 - -1.0 3 10 6 Number of results in the range -1.01 - 1 4 6 Treasury estimates (1980) -0.2 -1.1 -1.6 Treasury estimates (1987) -0.5 -1.3 -1.3 Treasury estimates (1992) -1.0 -1.1 -0.9
Source Raistrick et al 1999.
22
Population groups 4.5 The evidence concerning the distribution of effects across the population is variable.One study reports that moderate drinkers are more price responsive than heavy drinkers. Inanother study, the largest effect was found in the 80%-90% band of the population whenordered by level of alcohol consumption (Raistrick et al 1999). 4.6 The evidence relating to under-age and youth drinking is unclear. Other interventions,such as drink drive penalties, may be more effective than price in determining the behaviourof college students (NIAAA 2000).
Quality and relevance of evidence 4.7 The methods and data vary between studies and the estimates are not particularly up todate. However, the direction of the price effect is clear and the main uncertainty relates to thesize of the effect.
DRINK DRIVE LEGISLATION
Types of intervention 4.8 In the US, legislation has been enacted to introduce lower permitted blood alcohollevels for younger drivers and for persons with previous convictions for drink driving. Therehave also been reductions in permitted alcohol levels for all drivers. A number of laws havebeen passed to bring into force additional sanctions for drink driving, such as mandatorylicence suspension and ignition interlock devices.
Evidence of effectiveness 4.9 The effectiveness of drink driving legislation depends upon enforcement and not justthe enactment of the legislation. Evidence concerning the effectiveness of specificenforcement actions is considered in the next chapter. However, the levels of effectivenessindicated by studies attempting to evaluate the impact of the legislation will undoubtedlycontain some element relating to enforcement. 4.10 The introduction of zero levels of permitted alcohol consumption for drivers under 21has resulted in a 20% decline in crashes likely to involve alcohol; i.e. night-time singlevehicle crashes (NIAAA 2000). Six studies have found a reduction in injuries or crashesfollowing the legislation but half of these were not statistically significant (Zwerling andJones 1999). One US State has introduced lower levels of permitted alcohol for drivers witha previous conviction and the effect of this was positive (NIAAA 2000). 4.11 Reducing blood alcohol levels from 0.10 percent to 0.08 percent for other drivers inthe US has reduced alcohol related fatal crashes (NIAAA 2000). It should be noted that thishas the effect of reducing permitted levels in the US to the current permitted level in the UK.
23
4.12 Legislation to allow automatic license suspension has reduced crashes and fatalities insome states (NIAAA 2000).
Population groups 4.13 The only specific groups considered are under-age drinkers and persons with previousconvictions, covered above.
Intensity of intervention. 4.14 In one study of lower blood alcohol levels for younger drivers, there was someevidence of an increasing effect on night-time single vehicle fatalities as the permitted levelof alcohol reduced:
• 7% reduction with .04%-.06%;• 17% reduction with .02%; and• 22% reduction with 0%.
For reference, the UK legal limit corresponds to .08%.
Quality and relevance of evidence 4.15 Wagenaar et al (1995) specifically reviewed the quality of the literature and found it tobe limited by weak study designs and reports failing to include basic data required for meta-analysis. There was some evidence of publication bias in the US literature. Studies withcomparison groups reported smaller effects than before and after designs. US studies usingdescriptive statistics only were likely to report larger effect sizes. The longer the follow-up,the smaller was the estimated intervention effect. 4.16 The US literature is particularly dominant in the evaluation of legislative changes asresearchers are able to conduct robust inter-State comparisons of different legislation orlegislation introduced at different times. However, the results from the US must beconsidered in the context of falling total consumption. Cross-national studies may be affectedby cultural differences that make results difficult to interpret. Caution should be exercised intranslating results from one country to another. Some States have introduced more than onelegislative change at the same time, making the effects difficult to estimate separately.
LICENSING
Types of intervention 4.17 Licensing controls can affect a range of issues, such as hours of operation for outletsselling alcohol, types of outlet permitted to sell alcohol, the density of outlets within an area
24
and the age at which alcohol can be legally purchased or consumed. In some countries, suchas the US, sales of alcohol may be controlled through public monopoly.
Evidence of effectiveness Licensing hours 4.18 The UK evidence related to the effect of licensing hours on alcohol consumption andalcohol-related problems is unclear. Some studies from other countries have suggested thatlonger hours increase alcohol related problems (Raistrick et al 1999). Outlet density 4.19 Higher outlet density may affect alcohol sales either through reducing the time andtravel costs involved in purchasing alcohol or through competitive pressure leading to pricereductions through promotional activities. There is some evidence that higher outlet densityis associated with higher sales and increased fatal crashes (NIAAA 2000). Whilst this findinghas been replicated in a number of countries, studies in the UK have produced mixed results(Raistrick et al 1999). Raistrick et al suggest that the evidence of an association betweennumber of outlets and alcohol consumption needs to be interpreted with care. Effects appearto vary with type of alcohol product. Different types of outlet may have different influencesparticularly on alcohol related problems. Outlet type 4.20 Evidence from Australia suggests that different licences are associated with differentlevels of alcohol related problems, with night-clubs and bars posing the highest risk (Raistricket al 1999). In the US, however, bars had a lower risk for motor vehicle accidents than otherlicensed outlets. US evidence also shows a difference between outlet types in sales to under-age persons. Grocery stores were more prepared to sell to minors than other types of outlet.Factors associated with lower sales to minors included being part of a chain, membership of atrade association and having a high proportion of income from alcohol sales (Raistrick et al1999). Age limits 4.21 In the US, 20 of 29 studies on the effects of raising the drinking age to 21 showedsignificant decreases in traffic crashes and traffic fatalities (NIAAA 2000). These studiesfrom the early 1980s showed a 10% - 15% drop in alcohol related traffic deaths among youth.There is some evidence of reduced alcohol consumption, with the proportion of high schoolseniors reporting drinking in the last month falling from 72% in 1980 to 51% in 1999. Thereis also a reported reduction in drinking among people aged 21-25 who grew up in States witha minimum legal drinking age of 21 (NIAAA 2000).
25
Quality and relevance of evidence 4.22 There are relatively few studies of licensing interventions and the results need to betreated with some caution. There are difficulties measuring the impact of age restrictionsbecause of high levels of under-age drinking
ADVERTISING CONTROLS
Types of intervention 4.23 Governments can potentially restrict the level of advertising and the content ofadvertising, either by legislative action or through voluntary agreements with the alcoholindustry. There may also be controls on promotional activities.
Evidence of effectiveness 4.24 There is little evidence relating to the impact of specific advertising controls. InCanada, full or partial advertising bans in some provinces did not provide any evidence of aneffect on total alcohol consumption. A comparison across 17 OECD countries did find anassociation between alcohol bans and reduced consumption (Raistrick et al 1999). However,statistical analysis of the relationship between expenditure on advertising and alcoholconsumption has failed to find any strong association. Experimental studies have foundeither no effect on beliefs and behaviours or small or short-term effects (NIAAA 2000).
Population groups 4.25 Survey research on alcohol advertising and young people shows a small butsignificant association between exposure to and awareness of advertising and drinking beliefsand behaviours (NIAAA 2000). The effectiveness of media literacy training for children alsoprovides at least indirect evidence of advertising effects on children (see Prevention).
Quality and relevance of evidence 4.26 The lack of evidence associating advertising and alcohol consumption may be theresult of there being relatively little change in spending compared to the total level ofspending. The effect of advertising bans in cross-country comparisons could be due toreverse causality; i.e. countries with low consumption being more likely to have alcoholadvertising bans.
FURTHER RESEARCH 4.27 The evidence relating to the size of the price effect could be improved and updated butany further studies should also focus on the distribution of effects and the impact on particular
26
problem behaviours. In the areas of drink driving and licensing, there is a lack of UKevidence and any new initiatives should be carefully evaluated. Longer-term follow up of theimpact of legislative action is also required.
27
Tab
le 4
.2Su
mm
ary
of P
olic
y an
d L
egis
lati
on E
ffec
tive
ness
Stu
dies
Rev
iew
ed A
utho
r(s)
and
Dat
e Se
arch
Stra
tegy
Incl
usio
n /
Exc
lusi
on C
rite
ria
Qua
lity
asse
ssed
Num
ber
ofst
udie
s T
arge
tG
roup
Mai
n Fi
ndin
gs
And
rew
s JC
The
Eff
ecti
vene
ss o
fA
lcoh
ol W
arni
ngL
abel
s: A
rev
iew
and
exte
nsio
n.A
mer
ican
Beh
avio
ural
Scie
ntis
t. 19
95;
38(4
): 6
22-3
2.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
Not
repo
rted
. L
imite
dde
tails
.P
regn
ant
wom
en,
wom
en,
and
youn
gpe
ople
are
invo
lved
inat
leas
t one
stud
y.
The
impa
ct o
f al
coho
l war
ning
mes
sage
s is
impr
oved
by
plac
ing
the
mes
sage
on
the
fron
t lab
el, i
n a
hori
zont
al p
ositi
on, w
ith th
e w
ords
“G
over
nmen
t War
ning
”,an
d by
red
ucin
g su
rrou
ndin
g cl
utte
r on
the
labe
l. W
hen
the
seve
rity
of
the
pote
ntia
l haz
ard
is s
ubst
anti
al, o
nly
expl
icit
info
rmat
ion
conv
eys
the
seve
rity
info
rmat
ion
adeq
uate
ly.
Tar
gete
d al
coho
l war
ning
pos
ters
hav
e be
en f
ound
toen
hanc
e th
e ex
posu
re, a
war
enes
s, a
nd k
now
ledg
e of
alc
ohol
war
ning
info
rmat
ion.
A
var
iety
of
impr
ovem
ents
are
rec
omm
ende
d to
enh
ance
the
impa
ct a
nd c
ompr
ehen
sion
of
the
war
ning
s. M
any
have
sug
gest
ed r
otat
ing
the
war
ning
labe
l inf
orm
atio
n an
d pr
esen
ting
new
and
spe
cifi
c in
form
atio
n to
red
uce
proc
essi
ng h
abitu
atio
n an
d in
atte
ntio
n. A
lso
sugg
este
d w
as th
at th
e le
vel o
fal
coho
l adv
ertis
ing
was
mat
ched
with
equ
ival
ent e
xpos
ure
of h
ealth
and
saf
ety
mes
sage
s. O
ne o
f th
e m
ost p
rom
isin
g av
enue
s to
exp
lore
is th
e go
al o
fin
crea
sing
not
onl
y th
e nu
mbe
r bu
t als
o th
e ef
fect
iven
ess
of a
lcoh
ol c
ount
er-
adve
rtis
ing
and
publ
ic s
ervi
ce a
nnou
ncem
ents
. N
atio
nal I
nstit
ute
on A
lcoh
ol A
buse
and
Alc
ohol
ism
,10
th S
peci
alR
epor
t to
the
US
Con
gres
s on
Alc
ohol
and
Hea
lth J
une
2000
T
axat
ion.
Pri
ce e
ffec
ts in
the
US
are
grea
ter
for
win
es a
nd s
piri
ts th
an b
eer.
Hig
her
taxe
s ar
e as
soci
ated
with
low
er tr
affi
c fa
talit
y ra
tes.
The
evi
denc
ere
latin
g to
pri
ce e
ffec
ts o
n un
der-
age
and
yout
h dr
inki
ng is
unc
lear
. Se
veri
ty o
fdr
ink
driv
e pe
nalti
es a
ppea
rs to
hav
e m
ore
impa
ct o
n co
llege
stu
dent
s th
anpr
ice.
Dri
nk d
rivi
ng.
In th
e U
S, th
e in
trod
uctio
n of
zer
o le
vels
of
perm
itted
alc
ohol
cons
umpt
ion
for
driv
ers
unde
r 21
has
res
ulte
d in
a 2
0% d
eclin
e in
cra
shes
like
lyto
invo
lve
alco
hol.
Red
ucin
g bl
ood
alco
hol l
evel
s fr
om 0
.10%
to 0
.08%
for
othe
r dr
iver
s ha
s re
duce
d al
coho
l rel
ated
fat
al c
rash
es.
Leg
isla
tion
to a
llow
auto
mat
ic li
cens
e su
spen
sion
has
red
uced
cra
shes
and
fat
aliti
es.
Som
e St
ates
have
intr
oduc
ed b
oth
chan
ges
mak
ing
the
effe
cts
diff
icul
t to
esti
mat
e se
para
tely
.O
ne S
tate
intr
oduc
ed lo
wer
leve
ls o
f pe
rmitt
ed a
lcoh
ol f
or d
rive
rs w
ith a
prev
ious
con
vict
ion
and
the
effe
ct o
f th
is w
as p
ositi
ve.
Lic
ensi
ng.
In th
e U
S, 2
0 of
29
stud
ies
on th
e ef
fect
s of
rai
sing
the
drin
king
age
to 2
1 sh
owed
sig
nifi
cant
dec
reas
es in
traf
fic
cras
hes
and
traf
fic
fata
litie
s. T
here
is s
ome
evid
ence
of
redu
ced
alco
hol c
onsu
mpt
ion.
Hig
her
outle
t den
sity
isas
soci
ated
wit
h hi
gher
sal
es a
nd in
crea
sed
fata
l cra
shes
.
28
Adv
ertis
ing.
The
eff
ect o
f ad
vert
isin
g on
tota
l con
sum
ptio
n is
not
sig
nifi
cant
but a
dver
tisin
g ap
pear
s to
infl
uenc
e ch
ildre
n’s
attit
udes
. R
aist
rick
DH
odgs
on R
Rits
on B
Tac
klin
g A
lcoh
olT
oget
her.
The
Evi
denc
e B
ase
for
UK
Alc
ohol
Pol
icy.
199
9Fr
ee A
ssoc
iati
onB
ooks
Lon
don
T
axat
ion.
Bot
h pr
ice
and
inco
me
affe
ct th
e le
vel o
f al
coho
l con
sum
ptio
nth
roug
h th
e af
ford
abili
ty o
f al
coho
l. P
rice
can
be
infl
uenc
ed to
som
e ex
tent
by
taxa
tion
. T
he s
ize
of p
rice
eff
ects
var
ies
acro
ss ty
pes
of a
lcoh
ol a
nd th
e im
pact
on s
peci
fic
grou
ps, s
uch
as b
inge
dri
nker
s is
less
cer
tain
. O
ne s
tudy
rep
orts
heav
y dr
inke
rs a
s le
ss p
rice
res
pons
ive
than
mod
erat
e dr
inke
rs; a
noth
er s
tudy
foun
d th
e la
rges
t eff
ects
in th
e 80
% -
90%
gro
up w
hen
the
popu
latio
n w
asor
dere
d in
term
s of
alc
ohol
con
sum
ptio
n. A
num
ber
of U
S st
udie
s ha
ve f
ound
that
pri
ce in
crea
ses
can
redu
ce a
lcoh
ol-r
elat
ed p
robl
ems,
suc
h as
dri
nk d
rivi
ngfa
talit
ies.
Lic
ensi
ng.
The
re is
som
e ev
iden
ce o
f an
ass
ocia
tion
bet
wee
n nu
mbe
r of
out
lets
and
alco
hol c
onsu
mpt
ion
but i
t nee
ds to
be
inte
rpre
ted
wit
h ca
re.
Eff
ects
app
ear
to v
ary
with
type
of
alco
hol p
rodu
ct.
Dif
fere
nt ty
pes
of o
utle
t may
hav
edi
ffer
ent i
nflu
ence
s pa
rtic
ular
ly o
n al
coho
l rel
ated
pro
blem
s. T
he e
vide
nce
rela
ted
to th
e ef
fect
of
lice
nsin
g ho
urs
on a
lcoh
ol c
onsu
mpt
ion
and
alco
hol-
rela
ted
prob
lem
s is
unc
lear
. E
vide
nce
from
oth
er c
ount
ries
sug
gest
s th
at a
gere
stri
ctio
ns p
reve
nt a
lcoh
ol-r
elat
ed p
robl
ems.
Adv
erti
sing
con
trol
s. S
tati
stic
al a
naly
sis
of a
dver
tisi
ng a
nd a
lcoh
olco
nsum
ptio
n ov
er ti
me
is v
ery
com
plex
and
all
stud
ies
have
met
hodo
logi
cal
prob
lem
s. M
ost s
tudi
es f
ind
little
impa
ct b
ut th
is c
ould
be
expl
aine
d by
the
rela
tivel
y sm
all y
ear-
on-y
ear
vari
atio
n in
adv
ertis
ing
expe
nditu
re.
Stud
ies
ofad
vert
isin
g ba
ns in
oth
er c
ount
ries
giv
e m
ixed
res
ults
and
pos
itive
eff
ects
cou
ldbe
cul
tura
lly d
eter
min
ed.
Adv
ertis
ing
and
the
posi
tive
port
raya
l of
drin
king
may
have
mor
e ef
fect
on
chil
dren
. W
agen
aar
AC
,Z
obec
k T
S,W
illia
ms
GD
,H
ings
on R
.M
etho
ds u
sed
inst
udie
s of
dri
nk-
driv
e co
ntro
lef
fort
s: A
met
a-an
alys
is o
f th
elit
erat
ure
from
1960
to 1
991.
Acc
iden
t
Yes
Stud
ies
incl
uded
had
a co
mpa
riso
ngr
oup,
or
am
atch
ed c
ontr
ol,
and
used
an
appr
opri
ate
outc
ome
mea
sure
.E
xclu
ded
stud
ies
wer
e in
divi
dual
site
or
stud
ies
that
wer
e du
plic
ate
repo
rts
of a
sin
gle
Yes
125
Not
repo
rted
. T
his
revi
ew c
over
ed b
oth
legi
slat
ion
and
enfo
rcem
ent.
In
the
US
, the
mos
tre
sear
ch a
ttent
ion
has
been
pai
d to
man
dato
ry ja
il se
nten
ce p
olic
ies
and
sele
ctiv
e en
forc
emen
t pat
rols
. In
tern
atio
nally
, ille
gal p
er s
e po
licie
s an
dso
brie
ty c
heck
-poi
nts
have
rec
eive
d th
e m
ost a
tten
tion
. T
he D
WI
cont
rol
liter
atur
e is
lim
ited
by th
e pr
epon
dera
nce
of w
eak
stud
y de
sign
s an
d re
port
s th
atof
ten
fail
to in
clud
e ba
sic
data
req
uire
d fo
r m
eta-
anal
ysis
. Fo
r U
S st
udie
s,jo
urna
l art
icle
s w
ere
mor
e lik
ely
to r
epor
t pos
itive
eff
ects
than
unp
ublis
hed
repo
rts,
con
sist
ent w
ith p
ublic
atio
n bi
as.
Inte
rnat
iona
l stu
dies
had
sim
ilar
resu
ltsfo
r bo
th jo
urna
l art
icle
s an
d un
publ
ishe
d re
port
s. S
tudi
es w
ith c
ompa
riso
ngr
oups
rep
orte
d sm
alle
r ef
fect
s th
an b
efor
e an
d af
ter
desi
gns.
US
stud
ies
usin
gde
scri
ptiv
e st
atis
tics
only
wer
e lik
ely
to r
epor
t lar
ger
effe
ct s
izes
but
this
was
not
foun
d in
the
inte
rnat
iona
l lite
ratu
re.
It w
as f
ound
that
the
long
er th
e fo
llow
-up
29
Ana
lysi
s &
Pre
vent
ion
1995
;27
(3):
307
-316
.
unde
rlyi
ng s
tudy
.N
ine
stud
ies
wer
eex
clud
ed a
s th
eyus
ed a
sign
ific
antly
diff
eren
t res
earc
hde
sign
.
the
smal
ler
the
esti
mat
ed in
terv
enti
on e
ffec
t. B
ecau
se p
olic
y m
aker
s an
d ot
hers
ofte
n ne
ed ti
mel
y in
form
atio
n re
gard
ing
effe
cts
of D
WI
cont
rol e
ffec
ts, s
hort
-te
rm f
ollo
w-u
p st
udie
s ar
e no
t nec
essa
rily
to b
e di
scou
rage
d. H
owev
er, l
onge
r-te
rm f
ollo
w-u
p st
udie
s be
yond
one
or
two
year
s ar
e pa
rtic
ular
ly n
eede
d if
ther
eis
to b
e la
stin
g pr
ogre
ss in
red
ucin
g D
WI
and
the
dam
age
it ca
uses
.
Wat
erso
n M
J.A
dver
tisin
g an
dal
coho
l: A
rev
iew
of th
e ev
iden
ce.
In, D
rink
ing
toyo
ur h
ealth
: the
alle
gatio
ns a
ndth
e ev
iden
ce. E
d.A
nder
son
D. T
heSo
cial
Aff
airs
Uni
t: L
ondo
n.19
89; 9
0-11
7.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
3 re
view
s of
the
empi
rica
lev
iden
ce a
redi
scus
sed
inco
nsid
erin
gw
heth
erad
vert
isin
gcr
eate
sde
man
d.
The
gene
ral
publ
ic.
One
rev
iew
cons
ider
edth
e ef
fect
of adve
rtis
ing
on y
oung
peop
le a
ndad
ults
sepa
rate
ly.
Inde
pend
ent r
evie
ws
of th
e lit
erat
ure
conf
irm
that
adv
ertis
ing
play
s an
insi
gnif
ican
t rol
e in
mou
ldin
g th
e br
oad
patte
rns
of d
eman
d fo
r pr
oduc
t gro
ups
such
as
drin
k. E
vide
nce
is c
ited
from
num
erou
s so
urce
s w
hich
sug
gest
s ve
ryst
rong
ly th
at tw
o of
the
mai
n ar
gum
ents
use
d by
cri
tics
of d
rink
adv
ertis
ing
(tha
tth
ere
is a
n ep
idem
ic o
f dr
inki
ng a
bout
whi
ch s
omet
hing
mus
t be
done
, and
that
sinc
e ad
vert
isin
g is
par
tly r
espo
nsib
le it
sho
uld
be s
topp
ed)
are
both
ser
ious
lyfl
awed
. It
is p
ossi
ble,
giv
en th
e la
ck o
f un
ders
tand
ing
of m
arke
t beh
avio
urex
hibi
ted
by m
any
crit
ics
that
pro
posa
ls f
or a
dver
tisi
ng b
ans
are
mad
e on
the
basi
s th
at n
othi
ng w
ill b
e lo
st s
houl
d th
e pr
opos
ed b
an p
rove
inef
fect
ive.
Exp
erie
nce
of th
e de
-reg
ulat
ion
of a
dver
tisin
g in
cer
tain
mar
kets
in th
e U
SA h
asde
mon
stra
ted
vivi
dly
just
how
impo
rtan
t to
the
cons
umer
the
free
dom
of
the
prod
ucer
to a
dver
tise
real
ly is
. T
he f
ree
flow
of
com
mer
cial
info
rmat
ion
isin
disp
ensa
ble.
Zw
erlin
g C
, Jon
esM
P E
valu
atio
n of
the
effe
ctiv
enes
sof
low
blo
odal
coho
lco
ncen
trat
ion
law
s fo
r yo
unge
rdr
iver
s. A
mer
ican
Jour
nal o
fP
reve
ntiv
eM
edic
ine
1999
:16
(1S
); 7
6S-8
0S.
Yes
Stud
ies
incl
uded
wer
e R
CT
s, c
ase-
cont
rol s
tudi
es,
coho
rt s
tudi
es o
rec
olog
ical
stu
dies
with
con
trol
or
com
pari
son
grou
ps a
nd d
ata
on o
bjec
tivel
ym
easu
red
outc
omes
.
Yes
6 st
udie
s m
etth
e in
clus
ion
crit
eria
.
You
ngdr
iver
s A
ll 6
stud
ies
foun
d a
redu
ctio
n in
inju
ries
or
cras
hes
afte
r th
e im
plem
enta
tion
ofth
e la
w b
ut h
alf
wer
e no
t sta
tistic
ally
sig
nifi
cant
. R
educ
tions
ran
ged
betw
een
11%
and
33%
. O
ne s
tudy
look
ed a
t dif
fere
nt le
vels
of
bloo
d al
coho
l and
fou
nda
dose
-res
pons
e ef
fect
. T
he la
rges
t eff
ects
(22
% r
educ
tion
) w
ere
in S
tate
s w
ith
zero
per
mit
ted
bloo
d al
coho
l, co
mpa
red
wit
h 0.
02%
(re
duct
ion
17%
) an
d0.
04%
-0.0
6% (
7 %
red
uctio
n).
31
CHAPTER FIVE ENFORCEMENT
SUMMARY
This chapter reviews the effectiveness and cost-effectiveness evidence relating tointerventions to enforce legislation. The main findings are:• there is limited evidence supporting community enforcement programmes for under-age
drinking in the US;• random breath testing has been effective in enforcing drink drive legislation in the US and
Australia, reducing fatalities, injuries and crashes;• a study modelling the costs and benefits of a sobriety checkpoint, using US data, showed
benefits in excess of costs; and• a study of a server training programme in the US also found benefits in excess of costs. Results based on US cost data cannot be directly translated to a UK setting. There is a lack ofUK data relating to enforcement actions.
INTRODUCTION 5.1 The previous chapter included evidence relating to legislative interventions. Theimpact of legislation also depends on the action taken to enforce the measures and thevisibility of the enforcement process. This chapter covers evidence relating to specificenforcement actions in the areas of:
• legal drinking age; and• drink driving.
The studies reviewed are summarised briefly in tables 5.2 (effectiveness) and 5.3 (cost-effectiveness) at the end of the chapter.
LEGAL DRINKING AGE
Types of intervention 5.2 Enforcement of under-age sales laws frequently takes the form of ‘decoy sales’, inwhich under-age buyers attempt to purchase alcohol under observation of the enforcementagency. Enforcement campaigns may be accompanied by media publicity and trainingschemes aimed at sales outlets.
Effectiveness 5.3 Communities Mobilizing for Change on Alcohol was an initiative in whichcommunities were encouraged to develop their own specific interventions to reduce under-
32
age access to alcohol (NIAAA 2000). Interventions, which varied across communities,included activities to enforce restrictions on sales of alcohol to minors. After 2 1/2 years, agechecks at outlets were more frequent and the likelihood of sales to minors reduced. 5.4 The Community Trials Project had 5 interacting components aimed at reducingalcohol related injuries and deaths. Results were mixed; for example, voluntary servertraining was not effective at the community level but outlets in intervention sites were half aslikely to sell alcohol to an apparent minor.
Quality and relevance of evidence 5.5 Only a small number of studies have been carried out and the results may be specificto the communities in which they were developed. Multi-agency interventions in the UKhave not been effectively evaluated.
DRIVING RELATED
Types of intervention 5.5 A range of interventions has been employed to enforce legislation relating to drinkingand driving. The main initiatives that have been subject to evaluation are:
ignition interlock devices. These require the driver to provide a breath sample beforestarting a vehicle. If the sample corresponds to a blood alcohol content above a pre-specified level the ignition is locked, preventing the vehicle being driven; ‘administrative per se’ licence suspension. This allows for the immediate suspensionof a driving licence subsequent to failing a sobriety test and without requiringconviction through the judicial system; and random alcohol screening. This involves stopping vehicles without prior suspicion ofalcohol use. In Australia, all drivers stopped have a breath test administered whereasin the US breath tests are administered only if the use of alcohol is suspected after thedriver has been stopped. Random alcohol screening works through both deterrenceand detection.
Sanctions against convicted drink drivers may include a range of interventions combininglicense penalties and treatment (Wells-Parker et al 1995).
Effectiveness 5.6 There is some evidence that ignition interlock devices may be effective in preventingre-offending during the time they are installed (Coben and Larkin 1999). Although there aresome design problems with the studies, the findings are confirmed by the one RCT in thisarea. The relative risk of re-offending was 0.36 for the interlock group (95% CI; 0.20,0.61).
33
5.7 The evidence relating to the effectiveness of administrative per se licence suspensionis mixed (McArthur and Kraus 1999). The intervention was effective in 3 states for at leastone year after initial licence suspension but did not work in two other states. 5.8 There is evidence to support the effectiveness of random alcohol screening (Peek-Asa1999). All studies except one showed reductions in fatalities, injuries and crashes and theexception could also be reanalysed to show a decrease. Decreases in alcohol related fatalitiesand injuries were greater than total decreases. The results were generally the same for studiesthat measured alcohol use directly and those that used proxy measures. Decreases weregenerally greater in Australia than in the US. (One excluded study from Sweden did not finda significant decrease).
Table 5.1 Range of reductions in traffic fatalities, injuries and crashes. Total decrease Alcohol related decrease Fatalities 16% to 29% 17% to 75%
Highest figure is from study in 2 small communities Injuries or crashes 10% to 28% 0% to 32%
Source: Peek-Asa 1999
Intensity of intervention. 5.9 With respect to random alcohol screening, two studies examined the effects of thelevel of enforcement. One found greater reductions with increased enforcement and onefound no effect.
Quality and relevance of evidence 5.10 For evaluations of ignition interlock devices, there was only one RCT and therandomisation process was inadequately described. All studies relied on re-arrest rates asoutcome measures and this is a relatively rare event. There was potential for allocation oflower risk offenders to ignition interlock programmes in non-randomised studies. There wasa lack of description of other components of repeat offender programmes or other sanctionsapplied. 5.11 The evaluations of administrative per se licence suspension included no randomisedor non-randomised controlled trials. Results are based on studies comparing events beforeand after introduction of laws. Whilst this may be an appropriate study design, it can bedifficult to attribute effects to the intervention, particularly when other initiatives may betaken at the same time. 5.12 The evaluation of random alcohol screening also relies on before and after studydesigns. Studies generally had short follow up periods and lacked direct measures of thenumber of impaired drivers involved in crashes. Proxy measures used included single vehicle
34
night-time crashes. There was a lack of multivariate analysis to control for other deterrenceprograms, resulting in a problem of attribution of effects as above. 5.13 A review of the methodology relating to drink driving studies found that most studieshad design flaws (Wagenaar et al 1995). In addition, there was insufficient reporting of datafor purposes of meta-analysis and most studies had relatively short follow up periods.
COST-EFFECTIVENESS
Alcohol server laws 5.14 Levy and Miller (1995) undertook a cost-benefit analysis to investigate a pilot schemeto forbid the serving of intoxicated drinkers. The analysis is based on a case study inWashtenaw, Michigan, of a server intervention programme (SIP). Data on the incidence ofadverse events were taken from police files from before and after the programme enforcingalcohol server laws. Costs of alcohol related adverse consequences were scaled down torepresent the Washtenaw County population. The population for the analysis was patronsdrinking at controlled establishments and the outcomes of interest were fatal and non-fatalinjuries as a consequence of drinking. Programme costs were based on local police costs($48,400) and publicising the programme and training costs ($3,000). The total benefits ofthe scheme were derived from the total US costs as a result of alcohol-related accidents andmedical care. Medical cost savings were an estimated $0.47 million, monetary benefits $3.7million and total comprehensive cost savings were $10.1 million. 5.15 Levy and Miller present benefits of the programme as much greater than costs.Applying before and after data for the SIP programme and then calculating the change incosts provides a significant positive cost saving to society. However, it is very difficult to seeexactly how the figures were calculated and other assumptions may yield different results, e.g.alternative sources of alcohol rather than exclusively licensed premises. The policy relevanceis limited outside the study area, as costs of incidents are very different, as are licensing laws.
Community sobriety checkpoint 5.16 Miller et al (1998) investigated the costs and benefits of a community sobrietycheckpoint program to reduce the incidence of drink driving and associated accidents in theUSA. The analysis was constructed using a hypothetical population of 100,000 licenseddrivers. Benefits were estimated using data from 1993 alcohol-involved crash incidence.Costs per crash were taken from published studies. Various estimates of the reduction inaccidents were used to estimate the benefits, with estimates taken from previously publishedstudies documenting crash reductions following similar programmes. Miller et al usedestimates of 5%, 10%, 15% and 20% reductions, and a rate of 250 driver stops per 4 hourcheckpoint. 5.17 The study was based on a hypothetical community of 100,000 drivers, with outcomesbased on averted fatalities, averted non-fatal injuries and averted property damage. The costsof the programme were police wages, checkpoint equipment (trailer and generator, breath test
35
equipment), and a mobile video system at a total cost of $39,000 (£26,500 1990 prices). Thebest estimate pointed to a reduction in alcohol related crashes by 15%. Benefits of theprogramme included $7.9 million savings in alcohol-related crashes and $0.3 million inaverted property damage. Annual operating costs were $1,181,000. Other costs were traveldelays ($44,000) and criminal justice costs ($172,000). Each of 156 checkpoints cost society$7570, imposed $2175 in costs to drivers and yielded $50,000 benefits. Every $1 invested inthe programme saved society an estimated $6.
FURTHER RESEARCH 5.18 There is a lack of UK evidence relating to enforcement actions. Random testing fordrink drivers emerges as the intervention most likely to have an effect but studies are neededto address the questions of how long the effects of enforcement actions are sustained and thelevel of enforcement that is optimal, in terms of costs and benefits. UK studies ofenforcement actions relating to under-age drinking are required.
36
Tab
le 5
.2Su
mm
ary
of E
nfor
cem
ent
Eff
ecti
vene
ss S
tudi
es R
evie
wed
Aut
hor(
s) a
nd D
ate
Sear
chSt
rate
gy In
clus
ion
/ Exc
lusi
onC
rite
ria
Qua
lity
asse
ssed
Num
ber
ofst
udie
s T
arge
tG
roup
Mai
n Fi
ndin
gs
Cob
en J
, Lar
kin
G.
Eff
ecti
vene
ss o
fig
nitio
n in
terl
ock
devi
ces
in r
educ
ing
drun
k dr
ivin
gre
cidi
vism
. A
mer
ican
Jour
nal o
f P
reve
ntat
ive
Med
icin
e 19
99;
16(1
S): 8
1-7.
Yes
. St
udie
s w
ere
incl
uded
ifth
ey w
ere
rand
omis
ed-
cont
rolle
d tr
ials
,co
ntro
lled
tria
ls, c
ase-
cont
rol s
tudi
es, c
ohor
tst
udie
s or
eco
logi
cal
stud
ies.
Stu
dies
wer
ere
quir
ed to
hav
e a
clea
rde
scri
ptio
n of
the
prog
ram
and
out
com
esev
alua
ted,
to h
ave
aco
mpa
riso
n gr
oup
and
topr
ovid
e in
terp
reta
ble
and
orig
inal
dat
a.
Not
rep
orte
d 6
stud
ies
revi
ewed
fro
man
initi
al s
et o
f31
Dri
vers
with
at le
ast o
nepr
ior
conv
ictio
nfo
r dr
ivin
gw
hile
into
xica
ted.
Five
of
the
6 st
udie
s fo
und
prog
ram
s ut
ilisi
ng ig
nitio
nin
terl
ocks
wer
e ef
fect
ive
in r
educ
ing
driv
ing
whi
lein
toxi
cate
d re
cidi
vism
. T
hree
of
thes
e st
udie
s ha
d no
n-ra
ndom
ised
gro
ups
and
one
was
a r
etro
spec
tive
stud
y. I
nth
ese
5 st
udie
s, p
artic
ipan
ts in
the
inte
rloc
k pr
ogra
ms
wer
e15
%-6
9% le
ss li
kely
than
con
trol
s to
be
re-a
rres
ted
for
DW
I. A
lcoh
ol ig
nitio
n in
terl
ock
prog
ram
s ap
pear
to b
eef
fect
ive
in r
educ
ing
DW
I re
cidi
vism
dur
ing
the
tim
epe
riod
whe
n th
e in
terl
ock
is in
stal
led
in th
e ca
r. F
utur
est
udie
s sh
ould
atte
mpt
to c
ontr
ol f
or e
xpos
ure
(i.e
. the
num
ber
of m
iles
driv
en)
and
dete
rmin
e if
cer
tain
sub
grou
psar
e m
ost b
enef
ited
by in
terl
ock
prog
ram
s.
McA
rthu
r D
L, K
raus
J.
The
spe
cifi
c de
terr
ence
of a
dmin
istr
ativ
e pe
r se
law
s in
red
ucin
g dr
unk
driv
ing
reci
divi
sm.
Am
eric
an J
ourn
al o
fP
reve
ntat
ive
Med
icin
e19
99; 1
6(1S
): 6
8-75
.
Yes
. T
hese
arch
stra
tegy
isde
scri
bed
in d
etai
l in
a se
para
tear
ticle
,R
ivar
a et
al
1999
Stud
ies
incl
uded
had
ade
fine
d co
hort
of
driv
ers
with
dri
ving
rec
ords
avai
labl
e af
ter
man
dato
ryli
cenc
e su
spen
sion
, a
com
pari
son
coho
rt n
otsu
bjec
t to
lice
nce
susp
ensi
on, a
nd r
elev
ant
and
inte
rpre
tabl
e da
tath
at le
ad to
an
obje
ctiv
eas
sess
men
t of
reci
divi
sm.
Not
rep
orte
d 3
coho
rtst
udie
s D
rive
rs.
Adm
inis
trat
ive
per
se la
ws,
gov
erni
ng li
cenc
e re
stri
ctio
nfo
r dr
iver
s, h
ave
been
sho
wn
to b
e ef
fect
ive
in s
ome
stat
esbu
t not
oth
ers
in d
ecre
asin
g th
e ra
tes
at w
hich
thes
e sa
me
driv
ers
are
subs
eque
ntly
invo
lved
in a
mot
or v
ehic
le c
rash
or in
ano
ther
alc
ohol
-rel
ated
off
ence
, com
pare
d w
ith
driv
ers
who
wer
e sa
nctio
ned
thro
ugh
othe
r co
nven
tiona
lju
dici
al p
roce
sses
. R
epli
cati
ons
are
need
ed in
oth
er s
tate
sor
larg
e dr
iver
pop
ulat
ions
usi
ng im
prov
ed m
etho
dolo
gy
Nat
iona
l Ins
titut
e on
Alc
ohol
Abu
se a
ndA
lcoh
olis
m, 1
0th
Spec
ial R
epor
t to
the
US
Con
gres
s on
Alc
ohol
and
Hea
lth
R
epor
ts o
n m
easu
res
to e
nfor
ce s
uspe
nsio
n of
rep
eat
offe
nder
s th
roug
h ve
hicl
e ta
ggin
g or
imm
obili
zatio
n an
dim
poun
ding
of
vehi
cles
. T
he e
vide
nce
for
the
form
er is
uncl
ear
and
the
latte
r is
rep
orte
d to
be
effe
ctiv
e. I
gniti
onin
terl
ock
devi
ces
are
effe
ctiv
e w
hile
fitt
ed.
Sobr
iety
che
ckpo
ints
and
ran
dom
bre
ath
test
ing
dete
r
37
June
200
0
drun
k dr
ivin
g. In
terv
entio
ns to
red
uce
unde
r-ag
e dr
inki
ng ,
as p
art o
fco
mm
unity
pre
vent
ion
stra
tegi
es, h
ave
had
som
e ef
fect
. Pe
ek-A
sa C
. T
heef
fect
of
rand
omal
coho
l scr
eeni
ng in
redu
cing
mot
or v
ehic
lecr
ash
inju
ries
.A
mer
ican
Jou
rnal
of
Pre
vent
ativ
e M
edic
ine
1999
; 16(
1S):
57-
67.
Yes
Stud
ies
incl
uded
eval
uate
d a
rand
omsc
reen
ing
prog
ram
,in
clud
ed a
n ob
ject
ivel
ym
easu
red
outc
ome,
and
had
a co
ntro
l gro
upan
d/or
com
pari
son
peri
od.
Stud
ies
wer
eex
clud
ed if
they
exam
ined
a n
umbe
r of
prev
enti
on m
easu
res
sim
ulta
neou
sly
and
did
not p
rese
nt r
esul
ts f
orra
ndom
scr
eeni
ngsp
ecif
ical
ly a
nd if
they
mea
sure
d ch
ange
s in
drin
king
dri
vers
with
out
rega
rd to
cra
shes
.
Yes
14 s
tudi
esfr
om U
S an
dA
ustr
alia
met
the
incl
usio
ncr
iteri
a
Dri
vers
Ran
dom
scr
eeni
ng a
ppea
rs to
be
effe
ctiv
e in
a w
ide
rang
eof
bot
h U
S an
d A
ustr
alia
n po
pula
tions
. D
espi
te th
e m
any
limita
tions
in th
e st
udie
s re
view
ed, t
he w
eigh
t of
evid
ence
indi
cate
s th
at r
ando
m s
cree
ning
red
uces
fat
aliti
es a
ndin
juri
es.
The
re w
as s
ome
disa
gree
men
t am
ong
stud
ies
asto
how
long
the
effe
cts
of r
ando
m a
lcoh
ol s
cree
ning
can
be
sust
aine
d an
d th
e le
vel o
f en
forc
emen
t nec
essa
ry, a
nd th
ese
rem
ain
ques
tion
s to
be
answ
ered
.
Rai
stri
ck D
Hod
gson
RR
itson
B T
ackl
ing
Alc
ohol
Tog
ethe
r. T
heE
vide
nce
Bas
e fo
r U
KA
lcoh
ol P
olic
y. 1
999
Free
Ass
ocia
tion
Boo
ks L
ondo
n
H
igh
prof
ile
poli
cing
of
lice
nsed
pre
mis
es is
ass
ocia
ted
with
a r
educ
tion
in a
rres
ts a
nd r
ates
of
crim
e. M
ulti-
agen
cy in
terv
enti
ons
in th
e U
K h
ave
not b
een
effe
ctiv
ely
eval
uate
d.
Wag
enaa
r A
C, Z
obec
kT
S, W
illia
ms
GD
,H
ings
on R
. Met
hods
used
in s
tudi
es o
fdr
ink-
driv
e co
ntro
lef
fort
s: A
met
a-an
alys
is o
f th
eli
tera
ture
fro
m 1
960
to19
91. A
ccid
ent
Yes
Stud
ies
incl
uded
had
aco
mpa
riso
n gr
oup,
or
am
atch
ed c
ontr
ol, a
nd h
adus
ed a
n ap
prop
riat
eou
tcom
e m
easu
re.
Exc
lude
d st
udie
s w
ere
indi
vidu
al s
ite r
epor
tsfr
om th
e U
S A
lcoh
olSa
fety
Act
ion
Pro
ject
Yes
125
Not
repo
rted
. T
his
revi
ew c
over
ed b
oth
legi
slat
ion
and
enfo
rcem
ent.
In
the
US,
the
mos
t res
earc
h at
tent
ion
has
been
pai
d to
man
dato
ry ja
il s
ente
nce
poli
cies
and
sel
ecti
ve e
nfor
cem
ent
patr
ols.
Int
erna
tiona
lly, i
llega
l per
se
polic
ies
and
sobr
iety
chec
k-po
ints
hav
e re
ceiv
ed th
e m
ost a
tten
tion
. T
he D
WI
cont
rol l
itera
ture
is li
mite
d by
the
prep
onde
ranc
e of
wea
kst
udy
desi
gns
and
repo
rts
that
oft
en f
ail t
o in
clud
e ba
sic
data
req
uire
d fo
r m
eta-
anal
ysis
. Fo
r U
S st
udie
s, jo
urna
lar
ticle
s w
ere
mor
e lik
ely
to r
epor
t pos
itive
eff
ects
than
38
Ana
lysi
s &
Pre
vent
ion
1995
; 27(
3): 3
07-3
16.
(ASA
P)
of th
e ea
rly
1970
s, o
r st
udie
s th
atw
ere
dupl
icat
e re
port
s of
a si
ngle
und
erly
ing
stud
y.N
ine
stud
ies
wer
eex
clud
ed a
s th
ey u
sed
asi
gnif
ican
tly d
iffe
rent
rese
arch
des
ign
from
all
the
othe
r st
udie
s
unpu
blis
hed
repo
rts,
con
sist
ent w
ith p
ublic
atio
n bi
as.
Inte
rnat
iona
l stu
dies
had
sim
ilar
resu
lts f
or b
oth
jour
nal
artic
les
and
unpu
blis
hed
repo
rts.
Stu
dies
with
com
pari
son
grou
ps r
epor
ted
smal
ler
effe
cts
than
bef
ore
and
afte
rde
sign
s. U
S st
udie
s us
ing
desc
ript
ive
stat
istic
s on
ly w
ere
likel
y to
rep
ort l
arge
r ef
fect
siz
es b
ut th
is w
as n
ot f
ound
inth
e in
tern
atio
nal l
itera
ture
. It
was
fou
nd th
at th
e lo
nger
the
follo
w-u
p th
e sm
alle
r th
e es
timat
ed in
terv
entio
n ef
fect
.B
ecau
se p
olic
y m
aker
s an
d ot
hers
oft
en n
eed
tim
ely
info
rmat
ion
rega
rdin
g ef
fect
s of
DW
I co
ntro
l eff
ects
,sh
ort-
term
fol
low
-up
stud
ies
are
not n
eces
sari
ly to
be
disc
oura
ged.
How
ever
, lon
ger-
term
fol
low
-up
stud
ies
beyo
nd o
ne o
r tw
o ye
ars
are
part
icul
arly
nee
ded
if th
ere
isto
be
last
ing
prog
ress
in r
educ
ing
DW
I an
d th
e da
mag
e it
caus
es.
Wel
ls-P
arke
r E
,B
ange
rt-D
row
ns R
,M
cMill
en R
, Will
iam
sM
. Fin
al r
esul
ts f
rom
am
eta-
anal
ysis
of
rem
edia
l int
erve
ntio
nsw
ith d
rink
/dri
veof
fend
ers.
Add
ictio
n19
95; 9
0(7)
: 907
-26.
Yes
Stud
ies
incl
uded
had
sam
ples
whi
ch in
clud
edD
UI
offe
nder
s an
d ha
d to
com
pare
rem
edia
tion
tono
rem
edia
tion
or to
com
pare
two
or m
ore
form
s of
rem
edia
tion.
Yes
194
stud
ies
Dri
nk d
rive
offe
nder
s T
he m
eta-
anal
ysis
est
ablis
hed
that
DU
I re
med
iatio
nge
nera
lly h
as a
pos
itive
eff
ect o
n al
coho
l-re
late
d tr
affi
cev
ents
– a
n ef
fect
of
at le
ast a
7-9
% r
educ
tion
in D
UI
reci
divi
sm a
nd a
lcoh
ol c
rash
es.
Rem
edia
tion
did
hav
epo
sitiv
e ef
fect
s on
alc
ohol
rel
ated
out
com
es.
With
in th
era
nge
of in
terv
entio
ns th
at h
ave
been
eva
luat
ed, t
heco
mbi
natio
n of
rem
edia
tion
with
lice
nsin
g ac
tion
appe
ars
mos
t lik
ely
to a
ffec
t pos
itive
ly b
oth
alco
hol-
rela
ted
traf
fic
even
ts a
nd m
ore
gene
ral t
raff
ic s
afet
y ou
tcom
es.
Rec
idiv
ism
ana
lyse
s su
gges
ted
that
som
e co
mbi
natio
ns o
fm
odal
ities
, in
part
icul
ar th
ose
incl
udin
g ed
ucat
ion,
psyc
hoth
erap
y/co
unse
llin
g an
d so
me
foll
ow-u
p, s
uch
asco
ntac
t pro
bati
on, s
how
ed la
rger
eff
ect s
izes
then
oth
erm
odes
, whi
le s
impl
e co
ntac
t pro
batio
n te
nded
, in
dire
ctw
ithin
-stu
dy c
ompa
riso
ns, t
o be
less
eff
ectiv
e th
aned
ucat
ion
or c
ombi
nati
on m
odes
. H
owev
er, t
he s
ocia
l and
poli
cy s
igni
fica
nce
of a
ny p
arti
cula
r in
terv
enti
on e
ffec
t,re
gard
less
of
its m
agni
tude
, mus
t be
dete
rmin
ed in
the
broa
der
aren
a of
per
sona
l and
soc
ial v
alue
s
39
Tab
le 5
.3Su
mm
ary
of E
nfor
cem
ent
Cos
t-E
ffec
tive
ness
Stu
dies
Rev
iew
ed
Stud
y T
ype
ofA
naly
sis
Popu
latio
n In
terv
entio
n O
utco
mes
Res
ults
Lev
y, D
. T. &
Mill
er, T
.R.,
Aco
st-b
enef
itan
alys
is o
fen
forc
emen
tef
fort
s to
red
uce
serv
ing
into
xica
ted
patr
ons,
Jou
rnal
of S
tudi
es o
nA
lcoh
ol, 1
995;
56:4
0-47
CB
A Pa
tron
s dr
inki
ng a
tco
ntro
lled
esta
blis
hmen
ts:
Cos
ts o
f al
coho
lre
late
d ad
vers
eco
nseq
uenc
es w
ere
scal
ed d
own
tore
pres
ent t
heW
asht
enaw
Cou
nty
popu
latio
n.
Pilo
t sch
eme
to f
orbi
dth
e se
rvin
g of
into
xica
ted
drin
kers
.T
he a
naly
sis
is b
ased
on a
cas
e st
udy
inW
asht
enaw
, Mic
higa
n.
Fata
l and
non
-fat
al in
juri
esas
a c
onse
quen
ce o
fdr
inki
ng.
The
pro
gram
me
cost
s w
ere
base
d on
loca
l pol
ice
cost
s($
48,4
00)
and
publ
icis
ing
the
prog
ram
me
and
trai
ning
cost
s ($
3,00
0).
The
tota
l ben
efits
of
the
sche
me
wer
ede
rive
d fr
om th
e to
tal U
S c
osts
as
a re
sult
of
alco
hol
rela
ted
acci
dent
s an
d m
edic
al c
are.
Med
ical
cos
t sav
ings
wer
e an
est
imat
ed $
0.47
mill
ion,
mon
etar
y be
nefi
ts $
3.7
mil
lion
and
tota
l com
preh
ensi
ve c
osts
wer
e $1
0.1
mill
ion.
Mill
er e
t al.
Cos
tsan
d be
nefi
ts o
f a
com
mun
ityso
brie
tych
eckp
oint
prog
ram
, Jou
rnal
of S
tudi
es o
nA
lcoh
ol. 1
998;
59:4
62-8
.
CB
A H
ypot
hetic
alco
mm
unity
of
100,
000
driv
ers
Com
mun
ity s
obri
ety
chec
kpoi
nt A
vert
ed f
atal
ities
, ave
rted
non-
fata
l inj
urie
s an
d av
erte
dpr
oper
ty d
amag
e
Bes
t est
imat
e po
ints
to r
educ
tion
in a
lcoh
ol r
elat
edcr
ashe
s by
15%
. B
enef
its o
f th
e pr
ogra
mm
e in
clud
e $7
.9m
illio
n sa
ving
s in
alc
ohol
rel
ated
cra
shes
, and
$0.
3m
illio
n in
ave
rted
pro
pert
y da
mag
e. A
nnua
l ope
ratin
gco
sts
wer
e $1
,181
,000
. Oth
er c
osts
wer
e tr
avel
del
ays
($44
,000
) an
d cr
imin
al ju
stic
e co
sts
($17
2,00
0).
Eac
h of
156
chec
kpoi
nts
cost
soc
iety
$75
70, i
mpo
sed
$217
5 in
cost
s to
dri
vers
and
yie
lded
$50
,000
ben
efits
. E
very
$1
inve
sted
in th
e pr
ogra
mm
e sa
ved
soci
ety
$6.
40
CHAPTER SIX PREVENTION
SUMMARY This chapter reviews the effectiveness and cost-effectiveness evidence relating to theprevention of problem drinking and alcohol abuse. The main findings are;• there is only weak evidence of effectiveness for school-based interventions;• evaluations tend to show changes in knowledge rather than behaviour;• characteristics which contribute to success are interactive design, parental, community
and peer involvement;• health promoting schools have some positive impacts but less on alcohol;• mass media campaigns affect knowledge and attitudes rather than behaviour;• screening and counselling adolescents was not cost-effective in one US study; and• thiamine supplementation of beer was shown to be cost-effective in preventing Wernicke-
Korsakoff encephalopathy in an Australian study. Better research designs are needed to provide more robust evidence in the area of prevention.
INTRODUCTION 6.1 This chapter concerns interventions to prevent alcohol misuse. The majority of theliterature is concerned with school-based interventions and these are summarised first. Thelimited evidence relating to other interventions, including mass media campaigns, is thenpresented. The studies reviewed are summarised briefly in tables 6.1 (effectiveness) and 6.2(cost-effectiveness) at the end of the chapter.
SCHOOL-BASED INTERVENTIONS
Introduction 6.2 Most school-based programmes are aimed at the prevention of substance misusegenerally and do not target alcohol alone. However, most evaluations report separate resultsfor the different substances of interest and the results for alcohol have been summarisedbelow. Much of the literature is drawn from the US and it is important to note that the aimswith respect to alcohol may be rather different. US programmes tend to focus on non-drinking and not sensible drinking.
Types of intervention 6.3 Interventions have been developing over time, with a movement away from factsbased teaching towards teaching social skills that will help in resisting social and peerpressure. As well as the content of the programme, the style of delivery can also beimportant. The main distinction drawn is between:
41
• interactive programmes, which include social influence and comprehensive lifeskills;
• interactive delivery, which requires elements such as participation, student tostudent communication, small group activities and corrective feedback; and
• non-interactive programmes, which are based on delivery of knowledge throughmainly didactic teaching.
6.4 One of the most widely evaluated programmes is Project DARE (Drug AbuseResistance Education), a widely used program in the US using trained police officers to teacha drug prevention curriculum (Ennet et al 1994). It comprises 17 weekly lessons of 45-60minutes teaching skills to recognise and resist social pressures to use drugs. 6.5 Another approach, used in Australia, involves parents and peers in the programme.The Illawarra Drug Education Programme is targeted at 10-11 year olds and begins with aparents’ evening. Children are introduced to the programme by peers; children whocompleted the programme the year before. The teaching phase is followed by group work anda drama production (described in Lloyd et al 2000). 6.6 The health promoting schools initiative is a relatively recent development and takes aholistic and whole school approach to health promotion. It requires a commitment to a safeand health-enhancing environment, as well as specific health promotion interventions (Lister-Sharp et al 1999).
Effectiveness 6.7 Evaluations of school-based interventions have produced relatively weak evidence ofeffectiveness, mainly showing changes in knowledge rather than behaviour. Reviews suggestthat half or less are partially effective in producing change on a range of outcome measures(Foxcroft et al 1997; Gorman 1996). 6.8 Interactive programmes have been shown to be more effective than non-interactiveprogrammes and Project DARE (Black et al 1998; Ennet et al 1994). Other characteristics ofprogrammes which appear to contribute to success are parental or community involvementand peer involvement. Media literacy training has been evaluated separately in 2 studies andwas shown to be effective (NIAAA 2000). 6.9 The Illawarra Drug Education Programme has had a delayed effect on level of alcoholuse 41/2 years after exposure to the project (Lloyd et al 2000). 6.10 The health promoting schools approach has been shown to have some positiveimpacts but is less successful at changing health damaging behaviours, such as alcoholmisuse (Lister-Sharp et al 1999).
42
Population groups 6.11 All interventions target school age children but the age groups vary and results forparticular interventions may not translate to other age groups. The majority of interventionsare aimed at the 11-14 age range.
Settings 6.12 No studies were found comparing alternative settings for the delivery of programmesto the target group.
Providers 6.13 Mental health clinicians, teachers and peers have all been shown to be effectiveproviders of interactive interventions, provided proper training is given (Black et al 1998).Choice of peers is an important factor.
Intensity of intervention 6.14 No studies have been undertaken to address this question directly. Whilst theintensity of interventions, in terms of contact hours, is variable, other aspects of theinterventions also vary.
Quality and relevance of evidence 6.15 There are concerns about the quality of the evaluations. In particular, the lack ofinformation about comparison schools makes the results difficult to interpret. It is likely thatsome form of drug use education was taking place in control schools and this would tend toreduce the effect of the programmes being evaluated. Longer-term follow up is required toestablish impact on behaviour.
OTHER HEALTH PROMOTION INTERVENTIONS Introduction 6.16 This section is concerned with other forms of health promotion that are notexclusively school-based. It includes mass media campaigns, community preventioninitiatives and other interventions.
43
Types of intervention 6.17 Mass media campaigns aim to communicate health promotion messages to the generalpopulation through a variety of media. They are rarely carried out within a research designthat allows robust evaluation to take place. Media campaigns can also form part ofenforcement programmes. 6.18 There have been relatively few evaluations of community prevention initiatives.Project Northland was a school and community intervention that combined education withcommunity action related to under-age drinking. Communities Mobilizing for Change onAlcohol (CMCA) aimed to reduce under-age drinking and related problems through reducingaccess to alcohol. The Communities Trials Project (CTP) aimed to reduce alcohol-relatedinjuries and deaths. Given the type of initiatives pursued, there is some overlap with thelegislation and enforcement literature but the focus of interest here is the community setting. 6.19 One review of health promotion for teenagers refers to a well adolescent clinic.
Effectiveness 6.20 In general, mass media campaigns relating to alcohol, tobacco or illicit drugs showsome effects on knowledge and attitudes but little on behaviour (Raistrick et al 1999). Massmedia campaigns can be successful if they model specific behaviours or target particularrisks, such as drink driving. 6.21 Project Northland resulted in reductions in alcohol use at 3 years. The othercommunity interventions had mixed results. CMCA produced changes in the desireddirection that were not statistically significant. Some but not all of the components of CTPwere effective. 6.22 The well adolescent clinic was shown to be effective in increasing knowledge aboutalcohol but behaviour was not evaluated (Walker and Townsend 1999).
Population groups 6.23 Apart from mass media campaigns, only CTP was aimed at a general population. Theother interventions were aimed at teenagers and minors.
Settings 6.24 No studies were found comparing alternative settings for the delivery of programmes.
Providers 6.25 No studies were found comparing alternative providers for the delivery ofprogrammes.
44
Intensity 6.26 The intensity of intervention was not addressed in the reviews. However, there maybe a cumulative effect in health promotion interventions.
Quality and relevance of evidence 6.27 There is a lack of good quality evaluations of community prevention and other healthpromotion activities relating to alcohol misuse.
COST-EFFECTIVENESS 6.28 No studies relating to schools programmes or community prevention programmeswere found in the literature. The economic evaluations of preventive interventions aresummarised below.
Adolescent counselling 6.30 In a US study, Downs and Klein (1995) analysed the cost-effectiveness ofimplementing office-based preventive services for adolescents. A cost-effectiveness model ofadolescents’ risky behaviours compared standard practice with a programme of screeningvisits for all adolescents and counselling visits for youths identified as 'high risk'. A range ofeffectiveness estimates was used to compute the estimated cost-effectiveness of theprogrammes. 6.31 Adolescents aged 15-19 were the treatment population and the costing was undertakenfrom a societal study perspective. One screening visit for all adolescents and threecounselling sessions for those screened as 'high risk' were compared to a simple 'nointervention' strategy. In a multiple risk intervention strategy, the outcome that related toalcohol abuse was motor vehicle crashes. The cost of each screening was $50 a session ($250for 5 screening events over 5 years) although it was not stated how this was derived, as unitcosts of inputs to care were not provided. 6.32 The results showed that at 5% efficacy the cost of preventing a motor vehicle crashwas $12,070 (£8,220) and the cost of preventing a death due to a motor vehicle crash was $12million (£8.17 million). The programme would prevent roughly one death from an alcoholrelated motor vehicle crash. Therefore, in terms of preventing alcohol problems, theprogramme does not appear cost-effective. It should be noted that these results are of limiteduse outside the area in which the study was undertaken, since not only are the riskybehaviours different but so are the motor vehicle statistics which generate the costs ofaccidents.
45
Prevention of Wernicke-Korsakoff syndrome 6.33 Connelly and Price (1996) examined the cost-effectiveness of thiamine-supplementation alternatives in preventing the Wernicke-Korsakoff syndrome (WKE) inAustralia. Based on 40 dietary and beverage histories, the conditions under which theindividuals would benefit from thiamine supplements were defined. The incidence of WKEwas calculated in Australia and the number of people expected to benefit from three schemeswas estimated. The three schemes were different degrees of thiamine supplementation;fortifying beer, fortifying beer and wine, and fortifying all bread making flours. Threepossible scenarios for the physiological benefits of thiamine were applied to forty subjects’histories. This gave the number of potential cases of WKE averted from the improvements.The total costs of fortifying beverages including equipment, additives, and assay costs wereAUS$1 662 390 for beer only, for beer and wines AUS$2 834 918 and for bread makingflours AUS$4 821 121. 6.34 The cost per case averted, based on projections between 1992 and 2031, ranged fromAUS$662 (£235) (fortifying just beer) to AUS$19 553 (£6900) (fortifying all bread makingflours) (discounted at 0%). Alternative assumptions regarding the physiological benefit andabsorption rates for thiamine, showed costs to range from AUS$1 104 (beers) to AUS$39 106(bread). The most cost-effective strategy for preventing WKE is fortifying full strength beerwith thiamine. The cost per case of WKE averted is least when beer alone is fortified. Thesecond most cost-effective strategy is supplementing beer and some wines, whilst the leastcost-effective is to supplement bread making flours with thiamine.
FURTHER RESEARCH 6.35 There is inadequate evidence concerning the effectiveness and cost-effectiveness ofinterventions to prevent alcohol misuse. The main requirement is for better designed studies,particularly with respect to the comparison groups, although in some areas there is a dearth ofany kind of study. 6.36 Much of the school-based health promotion literature reports results in terms of theeffect size relating to changes in the distribution of knowledge or attitude scores. However,evidence of a significant effect size needs to be further translated to understand whether thechange is important, in the same way that therapeutic studies may consider the clinicalimportance of differences in outcome. The reported effect sizes are often small but whetherthe effect size is worthwhile is unknown. Another area for research is the potential benefit oftargeting high-risk groups for health promotion. However, screening and intervening withhigh-risk adolescents has been shown not to be cost-effectiveness in one study. Such researchwould need to be carefully designed to avoid the danger of labelling effects. 6.37 There is little research evidence relating to the costs and benefits of communityinterventions. Evaluations should also consider the generalisability of communityprogrammes and their sustainability when resources to facilitate the community action arewithdrawn.
46
6.38 There is a continuing need to develop and evaluate novel interventions in healthpromotion. Research is also required to consider whether there is a cumulative effect ofexposure to health promotion messages.
47
Tab
le 6
.1Su
mm
ary
of P
reve
ntio
n E
ffec
tive
ness
Stu
dies
Rev
iew
ed A
utho
r(s)
and
Dat
e Se
arch
Stra
tegy
Incl
usio
n /
Exc
lusi
onC
rite
ria
Qua
lity
Ass
esse
d N
umbe
r of
stud
ies
Tar
get
Gro
up M
ain
Find
ings
Bag
nall
G a
ndFo
ssey
E A
lcoh
oled
ucat
ion
initi
ativ
es in
Scot
land
- a
cur
rent
pers
pect
ive.
Dru
gs: e
duca
tion,
prev
enti
on a
ndpo
licy
1996
; 3(3
):24
9-26
5
Not
rep
orte
d N
ot r
epor
ted
Not
rep
orte
d N
otre
port
ed N
otre
port
ed D
escr
iptiv
e re
view
of
initi
ativ
es in
Sco
tland
. D
iscu
sses
con
tent
of
scho
ol c
urri
culu
m a
nd ty
pes
of m
ater
ials
pro
duce
d fo
r us
e in
sch
ools
.In
nova
tive
sch
emes
incl
ude
invo
lvem
ent o
f he
alth
pro
ject
wor
kers
intw
o sc
hool
s, w
orkp
lace
sch
emes
, Gra
mpi
an S
erve
r T
rain
ing
Init
iati
vean
d de
sign
ated
dri
ver
sche
mes
. A
sch
eme
for
trai
ning
and
sup
port
ing
GP
s in
the
prov
isio
n of
bri
ef in
terv
entio
ns is
des
crib
ed (
Dri
nkin
gR
easo
nabl
y an
d M
oder
atel
y w
ith S
elf-
cont
rol (
DR
AM
S)).
No
eval
uati
on r
esul
ts a
re p
rovi
ded
for
any
of th
e sc
hem
es.
Bel
cher
HM
E,
Shin
itzky
HE
.Su
bsta
nce
Abu
se in
Chi
ldre
n:P
redi
ctio
n,pr
otec
tion,
and
prev
enti
on.
Arc
hive
s of
Pae
diat
ric
and
Ado
lesc
ent
Med
icin
e. 1
998;
152:
952
-60.
Yes
. St
udie
sin
clud
ed w
ere
cont
rolle
d,pr
ospe
ctiv
ean
d/or
long
itudi
nal o
fei
ther
pro
tect
ive
or r
isk
fact
ors
for
the
deve
lopm
ent o
fsu
bsta
nce
abus
eor
res
pons
e to
subs
tanc
e ab
use
prev
enti
onpr
ogra
ms.
Not
rep
orte
d. N
umbe
r of
stud
ies
not
repo
rted
,bu
t 18
diff
eren
tpr
even
tion
prog
ram
sw
ere
incl
uded
.
You
ng,
Und
er a
ge,
incl
uded
ethn
icgr
oups
and
vari
ous
soci
alcl
asse
s.
Stud
ies
have
fou
nd th
ere
is a
gen
etic
pre
disp
ositi
on f
or a
lcoh
ol a
buse
.B
iolo
gica
l chi
ldre
n of
alc
ohol
-dep
ende
nt p
aren
ts w
ho h
ave
been
adop
ted
cont
inue
to h
ave
an in
crea
sed
risk
(2-
to 9
- fo
ld)
ofde
velo
ping
alc
ohol
ism
. G
ende
r al
so a
ppea
rs to
be
a pr
edic
tive
fac
tor
for
alco
hol u
se. H
eavy
alc
ohol
use
is a
lmos
t 3 ti
mes
mor
e fr
eque
nt in
men
. C
hild
hood
abu
se h
as b
een
impl
icat
ed a
s a
sign
ific
ant r
isk
fact
orfo
r la
ter
subs
tanc
e ab
use.
Fac
tors
that
con
trib
ute
to th
e em
erge
nce
ofsu
bsta
nce
abus
e in
the
paed
iatr
ic p
opul
atio
n ar
e m
ulti
-fac
tori
al.
Beh
avio
ural
, em
otio
nal,
and
envi
ronm
enta
l fac
tors
that
pla
ce c
hild
ren
at r
isk
for
deve
lopm
ent o
f su
bsta
nce
abus
e m
ay b
e re
med
iate
dth
roug
h pr
even
tion
and
inte
rven
tion
prog
ram
s th
at u
se r
esea
rch-
base
d, c
ompr
ehen
sive
, cul
tura
lly r
elev
ant,
soci
al r
esis
tanc
e sk
ills
trai
ning
and
nor
mat
ive
educ
atio
n in
an
acti
ve s
choo
l-ba
sed
lear
ning
form
at.
Bla
ck D
R e
t al P
eer
help
ing/
invo
lvem
ent:
anef
fica
ciou
s w
ay to
mee
t the
cha
lleng
e
Not
rep
orte
d In
clud
ed s
tudi
esth
atco
ncur
rent
lyad
dres
sed
mul
tiple
Not
rep
orte
d 12
0 Y
oung
peop
le,
scho
olch
ildre
n(g
rade
s 6-
Bas
ed o
n a
met
a-an
alys
is r
epor
ted
sepa
rate
ly, t
his
pape
r is
con
cern
edw
ith th
e ge
nera
l les
sons
for
sch
ool-
base
d dr
ug p
reve
ntio
npr
ogra
mm
es.
Inte
ract
ive
peer
inte
rven
tion
s ar
e m
ore
effe
ctiv
e th
anno
n-in
tera
ctiv
e pr
ogra
mm
es in
min
imis
ing
alco
hol a
nd o
ther
subs
tanc
e us
e in
sch
ool c
hild
ren.
Thi
s is
sho
wn
in b
oth
high
qua
lity
48
of r
educ
ing
alco
hol,
toba
cco
and
othe
r dr
ug u
seam
ongs
t you
th?
Jour
nal o
f Sc
hool
heal
th 1
998;
68(
3):
87-9
3
subs
tanc
e us
e.8;
age
11-
14)
expe
rim
enta
l stu
dies
(56
) an
d th
e to
tal s
et o
f st
udie
s (1
20).
Inte
ract
ive
prog
ram
mes
wer
e al
so s
uper
ior
to D
AR
E.
Men
tal h
ealt
hcl
inic
ians
, tea
cher
s an
d pe
ers
wer
e al
l sho
wn
to b
e ef
fect
ive
as le
ader
spr
ovid
ed th
at p
rope
r tr
aini
ng w
as g
iven
. C
ites
two
stud
ies
whe
re p
eer
led
grou
ps w
ere
mor
e ef
fect
ive.
Mos
t stu
dies
wer
e co
nduc
ted
at a
ges
whe
re d
rug
use
is lo
wer
and
may
not
be
gene
ralis
able
to o
lder
age
grou
ps.
Rec
omm
ends
res
earc
h to
dev
elop
scr
eeni
ng te
sts
to ta
rget
prog
ram
mes
at h
igh-
risk
gro
ups.
Bru
vold
WH
. Am
eta-
anal
ysis
of
the
Cal
ifor
nia
scho
ol-
base
d ri
skre
duct
ion
prog
ram
.Jo
urna
l of
Dru
gE
duca
tion.
199
0;20
(2):
139-
52.
Not
repo
rted
. St
udie
sin
clud
ed h
ad a
cont
rol o
rco
mpa
riso
ngr
oup;
pre
-in
terv
entio
nas
sess
men
t of
inte
rven
tion
and
com
pari
son
grou
ps o
nkn
owle
dge
and
beha
viou
rs; a
ndm
easu
rem
ents
that
trac
ked
indi
vidu
alch
ange
on
each
cons
truc
tas
sess
ed
The
incl
usio
ncr
iter
ia u
sed
ensu
red
only
stud
ies
with
soun
dm
etho
dsw
ere
incl
uded
inth
e re
view
.
8 st
udie
s. Y
oung
,Sc
hool
pupi
ls.
The
aim
was
to
dete
rmin
e w
heth
er i
nter
vent
ions
bas
ed u
pon
diff
eren
tm
odel
s ha
ve d
iffe
rent
eff
ects
on
know
ledg
e, a
ttitu
des,
and
beh
avio
urre
gard
ing
alco
hol a
nd to
bacc
o pr
oduc
ts.
Eff
ect
size
s av
erag
ed o
ver
alco
hol
anal
yses
for
kno
wle
dge,
atti
tude
and
beha
viou
ral
outc
omes
ind
icat
e th
at r
atio
nal
prog
ram
s ha
ve l
arge
ref
fect
siz
es f
or k
now
ledg
e (0
.61)
tha
n do
dev
elop
men
tal
prog
ram
s(0
.26)
. T
he r
ever
se i
s in
dica
ted
for
attit
ude
and
beha
viou
r ou
tcom
esw
here
dev
elop
men
tal
prog
ram
s ha
ve l
arge
r av
erag
e ef
fect
siz
es.
(-0.
01,
0.02
-
ratio
nal
prog
ram
s an
d 0.
04,
0.20
–
deve
lopm
enta
lpr
ogra
ms)
res
pect
ivel
y.
It i
s im
port
ant
to k
now
whi
ch o
f th
e 4
theo
reti
cal
appr
oach
es (
rati
onal
, so
cial
lea
rnin
g, d
evel
opm
ent,
and
soci
al n
orm
s) i
s m
ost
effi
caci
ous
in d
eter
ring
ado
lesc
ents
fro
m t
heus
e of
alc
ohol
. D
evel
opm
enta
l in
terv
enti
ons
(aim
ed a
t ch
angi
ngat
titud
e an
d be
havi
our)
see
m t
o be
mor
e ef
fect
ive
whe
n ba
sed
oncl
earl
y id
entif
ied
theo
retic
al b
asis
. I
t ap
pear
s th
at t
he i
nfor
mat
iona
lor
rat
iona
l app
roac
h ha
s lit
tle s
yste
mat
ic im
pact
on
beha
viou
r an
d th
atal
tern
ativ
e ap
proa
ches
, su
ch a
s th
e de
velo
pmen
tal
appr
oach
, ha
vem
ore
prom
ise
for
actu
ally
det
erri
ng d
rug
use.
Tob
ler
NS
1986
, fou
nd s
imila
r re
sults
. E
nnet
t ST
et a
lH
ow e
ffec
tive
isdr
ug a
buse
resi
stan
ceed
ucat
ion?
A m
eta-
anal
ysis
of
Pro
ject
DA
RE
out
com
eev
alua
tion
s.A
mer
ican
Jou
rnal
of P
ublic
Hea
lth
Not
rep
orte
d In
clud
ed s
tudi
esw
ith c
ontr
ol o
rco
mpa
riso
ngr
oup,
bef
ore
and
afte
r de
sign
or p
ost
inte
rven
tion
with
ran
dom
assi
gnm
ent a
ndqu
antit
ativ
e
Yes
8 st
udie
sou
t of
18m
et th
ein
clus
ion
crit
eria
.
Scho
ol a
gech
ildre
n T
his
revi
ew p
rovi
des
a m
eta-
anal
ysis
of
eval
uatio
ns o
f D
AR
Epr
ogra
ms
and
a co
mpa
riso
n of
the
effe
ct s
ize
for
DA
RE
wit
h ot
her
scho
ol-b
ased
dru
g us
e pr
even
tion
prog
ram
mes
. O
nly
3 of
the
8D
AR
E s
tudi
es h
ad a
ny r
ando
mis
atio
n in
allo
catio
n of
sch
ools
; hal
fth
e st
udie
s m
atch
ed s
choo
ls o
n de
mog
raph
ic c
hara
cter
isti
cs.
All
stud
ies
adju
sted
for
pre
test
dif
fere
nces
in o
utco
me
mea
sure
s. E
ffec
t siz
e w
as g
reat
est f
or k
now
ledg
e (0
.42)
and
sm
alle
st a
nd n
otsi
gnif
ican
t for
dru
g us
e (0
.06)
. A
cros
s th
e ar
eas
of k
now
ledg
e,at
titud
es, s
ocia
l ski
lls a
nd d
rug
use,
eff
ect s
izes
for
DA
RE
wer
e le
ssth
an f
or o
ther
inte
ract
ive
prog
ram
mes
.
49
1994
; 84(
9): 1
394-
1401
outc
ome
mea
sure
s. E
valu
atio
ns la
cked
info
rmat
ion
on in
terv
entio
ns th
at m
ay h
ave
take
npl
ace
in c
ontr
ol g
roup
s an
d it
is li
kely
that
som
e dr
ug e
duca
tion
took
plac
e. Fo
xcro
ft D
R e
t al
Alc
ohol
mis
use
prev
enti
on f
oryo
ung
peop
le: a
syst
emat
ic r
evie
wre
veal
sm
etho
dolo
gica
lco
ncer
ns a
nd la
ckof
rel
iabl
e ev
iden
ceof
eff
ecti
vene
ss.
Add
ictio
n 19
97;
92(5
): 5
31-5
37
Yes
Incl
uded
eval
uati
ons
ofpr
imar
y or
seco
ndar
ypr
even
tion
prog
ram
mes
with
expe
rim
enta
l or
quas
i-ex
peri
men
tal
desi
gn.
Yes
48 p
aper
sco
veri
ng33
stu
dies
.22
wer
ege
nera
ldr
ugm
isus
e an
d11
targ
eted
alco
hol
You
ngpe
ople
aged
8-2
5
Onl
y 10
stu
dies
met
all
4 co
re r
equi
rem
ents
on
qual
ity c
rite
ria.
Ove
rall
, no
prog
ram
me
was
judg
ed to
be
conv
inci
ngly
eff
ecti
ve.
Hal
fth
e pr
ogra
mm
es w
ere
part
ially
eff
ectiv
e, in
that
som
e of
the
self
repo
rt m
easu
res
wer
e po
sitiv
ely
infl
uenc
ed in
fol
low
up
at o
ne y
ear.
One
of
thes
e w
as a
soc
ial s
kills
pro
gram
me
with
you
ng o
ffen
ders
inSc
otla
nd.
One
stu
dy w
ith lo
ng te
rm f
ollo
w u
p (6
yea
rs)
was
par
tially
effe
ctiv
e. T
his
Lif
e Sk
ills
Tra
inin
g in
terv
entio
n pr
oduc
ed a
10%
drop
in p
reva
lenc
e of
sel
f re
port
ed d
runk
enne
ss.
Mos
t of
the
stud
ies
revi
ewed
wer
e of
US
ori
gin
and
thei
r ai
m w
asno
n-dr
inki
ng r
athe
r th
an s
ensi
ble
drin
king
.
Gor
man
DM
. Are
scho
ol-b
ased
resi
stan
ce s
kills
trai
ning
pro
gram
sef
fect
ive
inpr
even
ting
alc
ohol
mis
use?
Jou
rnal
of
Alc
ohol
and
Dru
gE
duca
tion.
199
5;44
1(1)
: 74-
98.
Not
repo
rted
. St
udie
sin
clud
ed h
ad a
rese
arch
des
ign
invo
lvin
g so
me
form
of
com
pari
son
grou
p an
das
sess
edou
tcom
e in
term
s of
alc
ohol
use
rath
er th
anat
titud
es.
Not
rep
orte
d. 16
stu
dies
. Y
oung
peop
leag
ed 1
0 to
18 y
ears
.
The
aim
was
to in
vest
igat
e th
e ef
fect
iven
ess
of r
esis
tanc
e sk
ills
trai
ning
pro
gram
s in
red
ucin
g al
coho
l mis
use.
Of
the
16 s
tudi
esre
view
ed, 2
fou
nd n
egat
ive
effe
cts,
8 f
ound
litt
le o
r no
eff
ects
, 2fo
und
min
or e
ffec
ts, a
nd 4
fou
nd p
ositi
ve e
ffec
ts o
f re
sist
ance
ski
llstr
aini
ng p
rogr
ams
in r
educ
ing
alco
hol m
isus
e. R
ST p
rogr
ams
are
not
univ
ersa
lly e
ffec
tive.
In
the
stud
ies
repo
rtin
g a
posi
tive
effe
ct, t
his
islim
ited
to s
ub-g
roup
s of
the
targ
eted
pop
ulat
ion.
Thi
s lim
ited
effe
ctiv
enes
s is
not
sur
pris
ing
give
n th
at R
ST p
rogr
ams
targ
et ju
sttw
o of
the
know
n ri
sk f
acto
rs f
or a
lcoh
ol m
isus
e –
peer
pre
ssur
e an
dm
edia
infl
uenc
es.
Gor
man
DM
. Do
scho
ol-b
ased
soc
ial
skill
s tr
aini
ngpr
ogra
ms
prev
ent
alco
hol u
se a
mon
gyo
ung
peop
le?
Add
icti
on R
esea
rch
1996
; 4(2
): 1
91-
210.
Not
repo
rted
. St
udie
s w
ere
excl
uded
if th
eydi
d no
t em
ploy
an e
xper
imen
tal
or q
uasi
-ex
peri
men
tal
desi
gn w
ithbo
th b
asel
ine
and
post
-tes
tas
sess
men
t and
Not
rep
orte
d 12
stu
dies
Und
er a
ge,
You
ng(u
nder
18
year
s).
Six
of th
e 12
eva
luat
ions
of
soci
al s
kills
trai
ning
pre
vent
ion
prog
ram
sfo
und
little
or
no e
ffec
t on
part
icip
ants
’ al
coho
l use
and
rel
ated
beha
viou
r. O
nly
3 st
udie
s re
port
ed c
onsi
sten
tly p
ositi
ve r
esul
ts.
The
se s
tudi
es in
volv
ed th
e fe
wes
t sub
ject
s (n
=23
9, n
=10
2 an
dn=
137)
, and
eac
h pr
esen
ted
diff
icul
ties
in th
e in
terp
reta
tion
of
find
ings
. It
is s
ugge
sted
that
res
ista
nce
skill
s tr
aini
ng m
ay a
ctua
llyin
crea
se a
dole
scen
ts’
perc
epti
on o
f th
e pr
eval
ence
of
alco
hol u
se b
yov
erst
atin
g th
e ex
tent
to w
hich
ther
e is
pre
ssur
e to
use
, and
hen
ce b
eco
unte
rpro
duct
ive.
It i
s al
so a
rgue
d th
at s
choo
l-ba
sed
prog
ram
s m
ust
be r
efin
ed in
term
s of
the
stra
tegi
es th
roug
h w
hich
they
are
del
iver
ed,
50
if th
ey d
id n
otre
port
pro
gram
effe
cts
on a
ctua
lal
coho
l use
.
and
mov
e aw
ay f
rom
the
“uni
vers
al”
appr
oach
and
tow
ard
“tar
getin
g”or
“m
atch
ing”
inte
rven
tions
mor
e ap
prop
riat
ely
to th
e pr
ofile
of
risk
fact
ors
evid
ent a
mon
g su
bgro
ups
with
in b
road
pop
ulat
ions
.
Gor
man
DM
, Spe
erP
W. P
reve
ntin
gA
lcoh
ol A
buse
and
Alc
ohol
-rel
ated
Pro
blem
s th
roug
hC
omm
unity
Inte
rven
tions
: Are
view
of
eval
uatio
n st
udie
s.P
sych
olog
y an
dH
ealth
. 199
6; 1
1:95
-131
.
Not
repo
rted
. In
clud
ed:
eval
uati
ons
ofpr
ojec
tsco
ncer
ned
wit
hal
coho
l abu
sepr
even
tion
and
the
prev
enti
onof
bot
h al
coho
lab
use
and
illic
itdr
ug u
se;
prog
ram
s w
hich
incl
uded
com
pone
nts
desi
gned
toaf
fect
the
know
ledg
e,at
titud
es a
nd/o
rbe
havi
our
of th
ege
nera
lpo
pula
ce o
f a
com
mun
ity;
repo
rts
deal
ing
with
the
desi
gn,
impl
emen
tatio
nan
d ev
alua
tion
of a
spe
cifi
cpr
even
tion
prog
ram
wer
ein
clud
ed.
Yes
. 8
stud
ies,
incl
udin
g 3
larg
e-sc
ale
proj
ects
rece
ntly
com
men
ced
in th
eU
SA.
Men
,W
omen
,Y
oung
,U
nder
age
.P
eopl
eliv
ing
inR
ural
and
Urb
anar
eas.
Peo
ple
who
are
heav
ydr
inke
rs.
The
pro
gram
s co
nsid
ered
in th
is r
evie
w h
ad li
mite
d im
pact
.Su
gges
ted
reas
ons
for
this
are
that
mos
t atte
mpt
s at
pre
vent
ing
alco
hol u
se a
nd a
buse
rel
y up
on in
divi
dual
-lev
el in
terv
enti
ons,
whi
chha
ve n
ot b
een
show
n to
lead
to s
ubst
antia
l, lo
ng-t
erm
cha
nge
inal
coho
l use
and
abu
se; t
hat m
ost p
reve
ntio
n ef
fort
s ta
ke th
e fo
rm o
fst
anda
rdis
ed p
rogr
ams
devi
sed
by o
utsi
de e
xper
ts, w
ith m
inim
alci
tizen
par
ticip
atio
n in
thei
r de
velo
pmen
t and
littl
e at
tent
ion
to th
eun
ique
sys
tem
s-le
vel f
acto
rs th
at g
ener
ate
alco
hol-
rela
ted
prob
lem
sw
ithin
the
targ
et c
omm
unity
; and
it h
as p
rove
d di
ffic
ult t
o ge
nera
teco
mm
unity
invo
lvem
ent i
n su
ch p
rogr
ams.
In
man
y pa
rts
of th
e U
SA,
inne
r ci
ty r
esid
ents
hav
e be
gan
to d
evel
op in
itiat
ives
des
igne
d, n
ot to
“ino
cula
te”
loca
l you
th a
gain
st a
lcoh
ol-r
elat
ed p
robl
ems,
but
rat
her
tolim
it th
e av
aila
bilit
y of
alc
ohol
with
in th
eir
com
mun
ities
and
reg
ulat
eth
e m
arke
ting
and
sal
es p
ract
ices
of
loca
l mer
chan
ts. P
reve
ntio
nre
sear
ch s
houl
d m
ove
away
fro
m th
e us
e of
sta
ndar
dise
d pr
ogra
ms
and
curr
icul
a to
war
ds a
mea
ning
ful i
nvol
vem
ent o
f lo
cal c
itiz
ens
inth
e de
sign
and
impl
emen
tatio
n on
com
mun
ity in
terv
entio
ns.
Lis
ter-
Shar
p D
et a
lH
ealth
pro
mot
ing
scho
ols
and
heal
thpr
omot
ion
in
Yes
1. R
evie
w o
fhe
alth
prom
otin
gsc
hool
s
Yes
1. 1
2st
udie
s m
etth
ein
clus
ion
Scho
olch
ildre
n T
his
was
a r
evie
w o
f al
l hea
lth p
rom
otio
n in
sch
ools
. T
he r
esul
ts f
oral
coho
l rel
ated
to 6
3 pr
ogra
mm
es r
epor
ting
alco
hol o
utco
mes
. O
fth
ese,
25
repo
rted
som
e sh
ort-
term
ben
efic
ial e
ffec
ts, 3
0 ha
d no
eff
ect
and
7 ha
d ne
gativ
e ef
fect
s. 1
4 pr
ogra
mm
es h
ad f
ollo
w u
p pe
riod
s of
51
scho
ols:
two
syst
emat
ic r
evie
ws.
Hea
lth T
echn
olog
yA
sses
smen
t 199
9;3(
22)
incl
uded
cont
rolle
d or
befo
re a
nd a
fter
stud
ies
repo
rtin
g al
lev
alua
ted
outc
omes
. 2.
Stu
dies
incl
uded
inre
view
of
revi
ews
ofef
fect
iven
ess
ofhe
alth
prom
otio
n in
scho
ols
had
syst
emat
icse
arch
es,
qual
ityas
sess
men
t of
stud
ies,
com
pari
son
grou
ps in
at
leas
t som
est
udie
s an
dre
port
ed s
tudy
deta
ils.
crite
ria
from
111
iden
tifie
d. 2.
32
revi
ews
met
the
incl
usio
ncr
iteri
afr
om o
ver
200
iden
tifie
d.4
had
alco
hol a
sth
eir
prim
ary
focu
s
6 m
onth
s or
mor
e an
d th
ose
whi
ch h
ad a
n ef
fect
on
beha
viou
rre
mai
ned
effe
ctiv
e fo
r up
to 2
yea
rs.
Tw
o pr
ogra
mm
es h
ad 5
yea
rfo
llow
up
and
one
of th
ese
show
ed s
igni
fica
nt e
ffec
ts (
Lif
e Sk
ills
Tra
inin
g).
Fact
ors
whi
ch in
crea
sed
the
succ
ess
of p
rogr
amm
es w
ere
peer
invo
lvem
ent,
incl
usio
n of
res
ista
nce
skill
s, s
tres
s m
anag
emen
t and
/ or
norm
set
ting,
and
par
enta
l inv
olve
men
t. T
he h
ealth
pro
mot
ing
scho
ols
appr
oach
can
hav
e a
posi
tive
impa
ctbu
t in
the
stud
ies
revi
ewed
was
less
like
ly to
cha
nge
beha
viou
rre
latin
g to
alc
ohol
mis
use
than
oth
er h
ealth
beh
avio
ur.
The
dir
ect c
osts
of
heal
th p
rom
otin
g sc
hool
s in
itiat
ives
in E
ngla
nd a
rere
port
ed a
s £6
000
per
scho
ol p
er y
ear.
Llo
yd C
et a
l T
heef
fect
iven
ess
ofP
rim
ary
Scho
olD
rug
Edu
catio
n.D
rugs
: edu
catio
n,pr
even
tion
and
polic
y 20
00; 7
(2):
109-
126
Not
rep
orte
d In
clud
edev
alua
tion
s of
prog
ram
mes
whi
ch in
clud
edill
icit
drug
s.A
lcoh
ol o
nly
stud
ies
wou
ldbe
exc
lude
d
Not
rep
orte
d 3
stud
ies
inth
e U
K a
nd8 el
sew
here
.
Chi
ldre
nag
ed 3
-15.
Eva
luat
ions
tend
to f
ocus
on
proc
ess
or in
term
edia
te o
utco
mes
;kn
owle
dge,
atti
tude
and
soc
ial s
kills
. No
alco
hol r
elat
ed r
esul
ts a
rere
port
ed f
or U
K s
tudi
es.
In th
e U
S, D
rug
Abu
se R
esis
tanc
eE
duca
tion
(DA
RE
) sh
ows
som
e sh
ort-
term
eff
ects
whi
ch d
isap
pear
over
long
er-t
erm
fol
low
up.
Lif
e E
duca
tion
Cen
tres
hav
e be
enpo
pula
r w
ith
chil
dren
and
teac
hers
but
are
not
wel
l-ev
alua
ted.
An
Aus
tral
ian
prog
ram
me
targ
eted
at a
ges
10-1
1 sh
owed
a d
elay
ed e
ffec
ton
leve
l of
alco
hol u
se a
fter
41 / 2
yea
rs.
A 5
yea
r pr
ogra
mm
e ta
rget
edat
hig
h ri
sk y
outh
sho
wed
a s
igni
fica
nt d
ecre
ase
in th
e pr
opor
tion
ever
usin
g al
coho
l and
in th
e pr
opor
tion
usin
g al
coho
l in
the
past
30
days
. M
ay C
Res
earc
h N
ot r
epor
ted
Not
rep
orte
d N
ot r
epor
ted
Not
You
ng T
his
is a
n ea
rly
revi
ew o
f ed
ucat
iona
l int
erve
ntio
ns, m
ainl
y de
liver
ing
52
on a
lcoh
oled
ucat
ion
for
youn
g pe
ople
: acr
itic
al r
evie
w o
fth
e lit
erat
ure.
Hea
lth E
duca
tion
Jour
nal 1
991;
50(4
): 1
95-9
repo
rted
adul
ts,
adol
esce
nts
fact
s ab
out a
lcoh
ol.
The
se in
terv
enti
ons
prov
ide
know
ledg
e bu
t do
not c
hang
e at
titud
es o
r be
havi
our.
Whi
lst s
kills
bas
ed a
ppro
ache
sap
pear
mor
e pr
omis
ing,
the
earl
y ev
alua
tion
s re
view
ed h
ere
had
disa
ppoi
ntin
g re
sults
. M
ass
med
ia c
ampa
igns
als
o im
pact
on
know
ledg
e ra
ther
than
beh
avio
ur.
Str
uctu
ral c
onst
rain
ts o
n al
coho
lco
nsum
ptio
n m
ay b
e m
ore
effe
ctiv
e.
Mur
phy-
Bre
nnan
,M
G a
nd O
ei T
P S
Is th
ere
evid
ence
tosh
ow th
at f
etal
alco
hol s
yndr
ome
can
be p
reve
nted
?Jo
urna
l of
Dru
gE
duca
tion
199
929
(1)
: 5-2
4
Not
rep
orte
d Pr
imar
y an
dse
cond
ary
prev
enti
onpr
ogra
mm
esab
out a
lcoh
olus
e du
ring
preg
nanc
y
Not
rep
orte
d 5
stud
ies
Preg
nant
wom
en a
ndot
her
popu
latio
ngr
oups
Prev
enti
on s
trat
egie
s ha
ve b
een
aim
ed a
t rai
sing
aw
aren
ess
of F
AS
acro
ss a
ll g
roup
s an
d ha
ve b
een
effe
ctiv
e in
this
. T
his
awar
enes
s ha
sno
t bee
n tr
ansl
ated
into
beh
avio
ur c
hang
es in
hig
h ri
sk d
rink
ers.
The
futu
re p
rior
ity
shou
ld b
e te
achi
ng s
trat
egie
s fo
r be
havi
our
chan
ge.
Nat
iona
l Ins
titut
eon
Alc
ohol
Abu
sean
d A
lcoh
olis
m,
10th
Spe
cial
Rep
ort
to th
e U
S C
ongr
ess
on A
lcoh
ol a
ndH
ealth
Jun
e 20
00 .
Pr
ojec
t Nor
thla
nd w
as a
sch
ool a
nd c
omm
unity
bas
ed in
terv
entio
nta
rget
ed a
t 11-
14 y
ear
olds
. A
fter
3 y
ears
, stu
dent
s in
the
inte
rven
tion
site
s ha
d lo
wer
rat
es o
f al
coho
l use
. R
ates
of
use
did
not c
hang
e fo
rch
ildr
en w
ho w
ere
alre
ady
usin
g al
coho
l at t
he s
tart
of
the
stud
y. C
omm
uniti
es M
obili
zing
for
Cha
nge
on A
lcoh
ol w
as a
n in
itiat
ive
inw
hich
com
mun
ities
wer
e en
cour
aged
to d
evel
op th
eir
own
spec
ific
inte
rven
tion
s to
red
uce
unde
r-ag
e ac
cess
to a
lcoh
ol.
Inte
rven
tion
sva
ried
acr
oss
com
mun
ities
. A
lthou
gh c
hang
es o
ccur
red
in th
e de
sire
ddi
rect
ion,
they
wer
e no
t sta
tistic
ally
sig
nifi
cant
. T
he C
omm
unity
Tri
als
Pro
ject
had
5 in
tera
ctin
g co
mpo
nent
s ai
med
at
redu
cing
alc
ohol
rel
ated
inju
ries
and
dea
ths.
Res
ults
wer
e m
ixed
; for
exam
ple,
vol
unta
ry s
erve
r tr
aini
ng w
as n
ot e
ffec
tive
at t
he c
omm
unit
yle
vel b
ut o
utle
ts in
inte
rven
tion
site
s w
ere
half
as
likel
y to
sel
l alc
ohol
to a
n ap
pare
nt m
inor
. M
edia
lite
racy
inte
rven
tions
may
be
a co
mpo
nent
of
scho
ol e
duca
tion
prog
ram
mes
but
2 e
valu
atio
ns h
ave
show
n th
e ef
fect
iven
ess
of th
isap
proa
ch.
Alc
ohol
spe
cifi
c tr
aini
ng w
as m
ore
effe
ctiv
e th
an g
ener
alm
edia
lite
racy
inte
rven
tion.
The
eff
ect w
as g
reat
er o
n gi
rls
than
boy
s. R
aist
rick
D e
t al
Tac
klin
g A
lcoh
ol
Pers
onal
dev
elop
men
t pro
gram
mes
do
not a
ppea
r to
be
effe
ctiv
e in
prev
enti
ng a
lcoh
ol m
isus
e am
ongs
t ado
lesc
ents
. 5
out o
f 16
stu
dies
53
Tog
ethe
r T
heE
vide
nce
Bas
e fo
rU
K A
lcoh
olP
olic
y.19
99 F
ree
Ass
ocia
tion
Boo
ksL
ondo
n
of r
esis
tanc
e sk
ills
trai
ning
rep
orte
d po
sitiv
e fi
ndin
gs b
ut th
e ev
iden
ceis
not
str
ong;
for
exa
mpl
e, c
ontr
ols
wer
e no
t wel
l mat
ched
. E
valu
atio
ns o
f m
ass
med
ia e
duca
tion
cam
paig
ns s
how
som
e ef
fect
son
kno
wle
dge
and
attit
udes
but
littl
e on
beh
avio
ur.
Med
ia c
ampa
igns
may
be
mor
e ef
fect
ive
if ta
rget
ed a
t spe
cifi
c be
havi
ours
, suc
h as
dri
nkdr
ivin
g, a
nd w
hen
they
sup
port
com
mun
ity
acti
on.
Lit
tle
is k
now
nab
out t
he c
umul
ativ
e ef
fect
of
cam
paig
ns.
Run
dall
TG
and
Bru
vold
WH
Am
eta-
anal
ysis
of
scho
ol-b
ased
smok
ing
and
alco
hol u
sepr
even
tion
prog
ram
s. H
ealth
Edu
cati
onQ
uart
erly
198
8;15
(3):
317
-334
Not
rep
orte
d In
clud
edev
alua
tion
s of
scho
ol-b
ased
prog
ram
mes
with
aco
mpa
riso
n or
cont
rol g
roup
and
repo
rtin
gqu
antit
ativ
ere
sults
rel
atin
gto
beh
avio
ur,
attit
udes
or
know
ledg
e.
Yes
19 a
lcoh
olpr
ogra
mm
es
Scho
olch
ildre
n T
his
is a
n ol
der
revi
ew a
nd th
e pr
ogra
mm
es c
over
ed m
ay n
ot r
efle
ctcu
rren
t pra
ctic
e. A
ll o
f th
e al
coho
l stu
dies
sho
wed
incr
ease
s in
know
ledg
e. M
ost o
f th
e al
coho
l stu
dies
cha
nged
stu
dent
atti
tude
s bu
tef
fect
siz
es w
ere
smal
ler.
Eff
ect s
izes
for
beh
avio
ur c
hang
e w
ere
also
smal
l. I
nnov
ativ
e in
terv
entio
ns (
soci
al r
einf
orce
men
t, so
cial
nor
ms
and
deve
lopm
enta
l beh
avio
ural
mod
els)
are
mor
e ef
fect
ive
than
trad
ition
al a
war
enes
s pr
ogra
mm
es.
Spot
h R
, Red
mon
dC
, Lep
per
H.
Alc
ohol
initi
atio
nou
tcom
es o
fun
iver
sal f
amily
-fo
cuse
dpr
even
tativ
ein
terv
entio
ns: O
nean
d tw
o ye
arfo
llow
-ups
of
aco
ntro
lled
stud
y.Jo
urna
l of
Stud
ies
on A
lcoh
ol 1
999;
13: 1
03-1
1.
Not
repo
rted
. N
ot r
epor
ted.
Yes
4 st
udie
sw
ere
iden
tifie
dfr
om o
ther
revi
ews.
One
rela
ted
toth
e pr
ojec
tre
port
ed in
the
pape
r.
Men
,W
omen
,Y
oung
,U
nder
age
,R
ural
.
Thi
s st
udy
give
s an
ove
rvie
w o
f th
e lit
erat
ure
on f
amily
foc
used
inte
rven
tions
and
rep
orts
res
ults
fro
m a
spe
cifi
c in
terv
entio
n (t
heIo
wa
Stre
ngth
enin
g Fa
mili
es P
roje
ct (
ISFP
)).
Fam
ily c
onte
xt f
acto
rsha
ve b
een
show
n to
be
impo
rtan
t in
expl
aini
ng v
aria
tion
in a
dole
scen
tal
coho
l out
com
es b
ut th
ere
is a
lack
of
good
qua
lity
eva
luat
ions
of
free
stan
ding
fam
ily in
terv
entio
ns.
Fam
ily c
ompo
nent
s of
wid
erst
udie
s, s
uch
as P
roje
ct N
orth
land
, cou
ld n
ot b
e se
para
tely
eva
luat
ed.
For
the
ISFP
, the
inte
rven
tion
redu
ced
the
prop
ortio
n of
chi
ldre
nbe
com
ing
alco
hol u
sers
at 1
and
2 y
ears
. A
t 1 y
ear,
eff
ect s
izes
wer
egr
eate
r fo
r fa
mili
es a
ttend
ing
at le
ast h
alf
of th
e se
ssio
ns b
ut th
isco
uld
be e
xpla
ined
by
self
-sel
ecti
on a
nd m
otiv
atio
n.
Tob
ler
NS.
Met
a-an
alys
is o
f 14
3ad
oles
cent
dru
g
Publ
ishe
dan
dun
publ
ishe
d
Incl
uded
stu
dies
had
quan
titat
ive
mea
sure
men
ts
Not
rep
orte
d 98
stu
dies
wer
ein
clud
ed,
You
ngpe
ople
soci
al
The
aim
was
to id
entif
y sp
ecif
ic m
odal
ities
or
com
bina
tions
of
mod
aliti
es w
hich
hav
e be
en e
ffec
tive
in r
educ
ing
the
high
inci
denc
eof
teen
age
drug
abu
se.
54
prev
enti
onpr
ogra
ms:
Qua
ntita
tive
outc
ome
resu
lts o
fpr
ogra
mpa
rtic
ipan
tsco
mpa
red
to a
cont
rol o
rco
mpa
riso
n gr
oup.
The
Jou
rnal
of
Dru
g Is
sues
. 198
6;16
(4):
537
-67.
liter
atur
ew
as s
earc
hed
from
197
2–19
84.
on r
elev
ant
outc
ome
mea
sure
s; a
cont
rol /
com
pari
son
grou
p; a
ge le
vel
incl
usiv
e of
seco
ndar
ysc
hool
popu
latio
n,gr
ades
5-1
2;an
d pr
imar
ypr
even
tion
as
the
goal
.
whi
chin
volv
ed14
3di
ffer
ent
prog
ram
mod
aliti
es.
clas
s,et
hnic
grou
ps,
urba
n an
dru
ral
loca
tions
.
For
143
drug
pre
vent
ion
prog
ram
s a
gran
d m
ean
(eff
ect s
ize)
of
0.30
was
mea
sure
d ov
er a
ll th
e ou
tcom
e m
easu
res.
Tw
o m
odal
ities
wer
eid
entif
ied
as b
eing
eff
ectiv
e. P
eer
Pro
gram
s w
ere
foun
d to
sho
w a
defi
nite
sup
erio
rity
for
the
mag
nitu
de o
f th
e ef
fect
siz
e ob
tain
ed o
n al
lou
tcom
e m
easu
res
(eff
ect s
ize
0.44
). T
his
was
don
e w
ith
low
inte
nsity
pro
gram
mes
mak
ing
them
ver
y co
st-e
ffec
tive
for
the
gene
ral
scho
ol-b
ased
pro
gram
s. A
ltern
ativ
e pr
ogra
ms
wer
e eq
ually
succ
essf
ul f
or th
e sp
ecia
l pop
ulat
ion
grou
ps, s
how
ing
supe
rior
res
ults
in in
crea
sing
ski
lls a
nd c
hang
ing
beha
viou
r in
bot
h di
rect
and
indi
rect
corr
elat
es o
f dr
ug u
se.
The
se p
rogr
ams
wer
e ve
ry in
tens
ive
and
invo
lved
cos
tly p
rogr
amm
ing,
but
they
did
cha
nge
the
beha
viou
r of
ane
arly
impl
acab
le p
opul
atio
n.
Tob
ler
NS,
Str
atto
nH
H. E
ffec
tive
ness
of s
choo
l-ba
sed
drug
pre
vent
ion
prog
ram
s: A
met
a-an
alys
is o
f th
ere
sear
ch. T
heJo
urna
l of
Pri
mar
yP
reve
ntio
n. 1
997;
18(1
):71
-128
.
Publ
ishe
dan
dun
publ
ishe
dre
port
s fr
ompu
blic
or
priv
ate
spon
sors
hips
at th
e lo
cal,
stat
e, a
ndna
tiona
lle
vels
wer
ese
arch
ed f
or.
Stud
ies
incl
uded
wer
e:sc
hool
-bas
eddr
ug p
reve
ntio
npr
ogra
ms;
use
dqu
antit
ativ
edr
ug u
sem
easu
res;
had
aco
ntro
l /co
mpa
riso
ngr
oup;
invo
lved
grad
es 6
-13;
had
goal
s of
prim
ary
and/
orse
cond
ary
prev
enti
onan
d/or
ear
lyin
terv
entio
n;in
volv
ed a
llet
hnic
gro
ups
that
com
pris
eth
e sc
hool
’spo
pula
tion;
Not
rep
orte
d.A
sub
set o
fhi
gh-q
ualit
yex
peri
men
tal
prog
ram
sw
ere
chos
ento
pre
vent
over
-es
timat
ion
ofpr
ogra
msu
cces
s an
dlim
itpo
tent
ial
sour
ces
ofbi
as.
90 s
tudi
esco
ncer
ning
120
prog
ram
s.O
f th
e 12
0pr
ogra
ms,
28 (
23.3
%)
conc
erne
dal
coho
l.
You
ngpe
ople
of
vari
ous
soci
alcl
ass,
ethn
icgr
oup,
and
urba
n an
dru
ral
loca
tions
.
For
the
28
stud
ies
conc
erni
ng
alco
hol
spec
ific
pr
ogra
ms
nosi
gnif
ican
t di
ffer
ence
w
as
foun
d be
twee
n th
e m
eans
of
th
e no
n-in
tera
ctiv
e an
d in
tera
ctiv
e pr
ogra
ms.
T
he i
nter
activ
e pr
ogra
ms
wer
esi
gnif
ican
tly b
ette
r th
an t
he n
on-i
nter
activ
e pr
ogra
ms
p=0.
000
(1st
post
-tes
t)
vers
us
p=0.
000
(mea
n ac
ross
tim
e).
T
he
inte
ract
ive
prog
ram
s w
ere
sign
ific
antly
bet
ter
than
non
-int
erac
tive
prog
ram
s in
the
set o
f 56
pro
gram
s; p
=0.
015
(1st p
ost-
test
) ve
rsus
p=
0.01
5 (a
cros
stim
e).
T
he
supe
rior
ity
of
the
inte
ract
ive
prog
ram
s to
th
e no
n-in
tera
ctiv
e pr
ogra
ms
was
bot
h cl
inic
ally
and
sta
tistic
ally
sig
nifi
cant
for
toba
cco,
al
coho
l, m
arij
uana
an
d il
lici
t dr
ugs
and
for
all
adol
esce
nts
incl
udin
g m
inor
ity p
opul
atio
ns.
The
lar
ger
inte
ract
ive
prog
ram
s w
ere
less
eff
ectiv
e, a
lthou
gh s
till
sign
ific
antly
sup
erio
r to
the
non-
inte
ract
ive
prog
ram
s, w
hich
sug
gest
s im
plem
enta
tion
failu
res.
Cur
rent
ly,
non-
inte
ract
ive
prog
ram
s ar
e us
ed b
y th
e ov
erw
helm
ing
maj
ority
of
scho
ols.
R
epla
cing
the
pre
sent
pro
gram
s w
ould
inc
reas
eth
e ef
fect
iven
ess
of s
choo
l-ba
sed
prog
ram
s by
8.5
% (
r =
0.0
85).
It
is
impo
rtan
t fo
r th
e sc
hool
s to
pro
vide
the
nec
essa
ry m
oney
, cla
ss t
ime,
extr
a pe
rson
nel
and
aggr
essi
ve
teac
her
trai
ning
in
th
e us
e of
inte
ract
ive
grou
p pr
oces
s sk
ills.
W
ithou
t th
e ex
tra
lead
ers
to f
orm
smal
l gr
oups
, th
e ad
oles
cent
s ca
n in
tera
ct o
nly
a fe
w t
imes
and
the
esse
ntia
l pa
rt
of
the
inte
ract
ive
prog
ram
s is
m
issi
ng,
that
of
invo
lvem
ent,
exch
ange
and
val
idat
ion
of i
deas
wit
h th
eir
peer
s, a
nden
ough
tim
e to
pra
ctic
e an
d tr
uly
acqu
ire
inte
rper
sona
l ski
lls.
55
loca
ted
in th
eU
S/C
anad
a; a
ndre
port
ed /
publ
ishe
d af
ter
1977
.
Wal
ker
ZA
K a
ndT
owns
end
J T
hero
le o
f ge
nera
lpr
acti
ce in
prom
otin
g te
enag
ehe
alth
: a r
evie
w o
fth
e lit
erat
ure.
Fam
ily P
ract
ice
1999
; 16(
2): 1
64-
172
Yes
Not
rep
orte
d N
ot r
epor
ted
T
eena
gers
Thi
s w
as a
gen
eral
rev
iew
of
heal
th p
rom
otio
n in
terv
entio
ns.
A w
ell-
adol
esce
nt c
lini
c fo
r 13
-18
year
old
s sh
owed
incr
ease
s in
kno
wle
dge
for
both
alc
ohol
and
mar
ijua
na w
hen
give
n ei
ther
com
pute
r as
sist
edin
stru
ctio
n or
phy
sici
an d
eliv
ered
gui
danc
e. B
ehav
iour
al o
utco
mes
wer
e no
t ass
esse
d.
Whi
te D
and
Pitt
sM
aria
n E
duca
ting
youn
g pe
ople
abo
utdr
ugs:
a s
yste
mat
icre
view
. A
ddic
tion
1998
; 93(
10):
1475
-148
7
Yes
Incl
uded
stu
dies
of p
sych
o-ed
ucat
iona
lpr
even
tion
mea
sure
s w
ith
cont
rol o
rco
mpa
riso
ngr
oups
and
bot
hba
seli
ne a
ndou
tcom
em
easu
res.
Yes
71 r
epor
tsof
62
sepa
rate
eval
uati
ons
You
ngpe
ople
aged
8-2
5
Sepa
rate
res
ults
for
alc
ohol
are
not
rep
orte
d. I
mpa
ct o
f pr
ogra
mm
esw
as s
mal
l and
tend
ed to
dim
inis
h ov
er ti
me.
The
bes
t tha
t was
achi
eved
was
a s
hort
-ter
m d
elay
in o
nset
of
drug
use
and
sho
rt-t
erm
redu
ctio
ns in
leve
l of
use
by th
ose
alre
ady
usin
g.
The
issu
e of
wha
tef
fect
siz
e is
a w
orth
whi
le o
utco
me
of a
n in
terv
entio
n is
rai
sed
but n
otan
swer
ed.
56
Tab
le 6
.2Su
mm
ary
of P
reve
ntio
n C
ost-
Eff
ecti
vene
ss S
tudi
es R
evie
wed
Stud
y T
ype
ofA
naly
sis
Popu
latio
n In
terv
entio
n O
utco
mes
Res
ults
Con
nelly
L a
nd P
rice
J.
Prev
entin
g th
eW
erni
cke-
Kor
sako
ffsy
ndro
me
in A
ustr
alia
:C
ost-
effe
ctiv
enes
s of
thia
min
-su
pple
men
tatio
nal
tern
ativ
es A
ustr
alia
nan
d N
ew Z
eala
ndJo
urna
l of
Publ
icH
ealth
199
6; 2
0(2)
:18
1-8.
Part
ial
Eva
luat
ion
Hyp
othe
tical
–Po
pula
tion
ofA
ustr
alia
Fort
ifyi
ng b
eers
and
win
es w
ithth
iam
ine
to p
reve
nt W
erni
cke-
Kor
sako
ff s
yndr
ome
Cas
es o
f W
K s
yndr
ome
aver
ted
Cos
t per
cas
e av
erte
d be
twee
n 19
92 a
nd20
31 r
ange
d fr
om A
US$
662
(for
tifyi
ngju
st b
eer)
to A
US$
1955
3 fo
rtif
ying
all
brea
d m
akin
g fl
ours
(di
scou
nted
at 0
%).
Alte
rnat
ive
assu
mpt
ions
reg
ardi
ng th
eph
ysio
logi
cal b
enef
it an
d ab
sorp
tion
rate
sfo
r th
iam
ine,
sho
wed
cos
ts to
ran
ge f
rom
AU
S$11
04 (
beer
s) to
AU
S$39
106
(bre
ad).
Dow
ns S
M, K
lein
JD
.C
linic
al p
reve
ntat
ive
serv
ices
eff
icac
y an
dad
oles
cent
s ri
sky
beha
viou
rs, A
rchi
ves
ofP
aedi
atri
c an
dA
dole
scen
t Med
icin
e.19
95; 1
49: 3
74-9
.
Part
ial
Eva
luat
ion
Ado
lesc
ents
age
d15
-19
(USA
) O
ffic
e ba
sed
inte
rven
tion
of o
nesc
reen
ing
visi
t for
all
adol
esce
nts
and
thre
eco
unse
lling
ses
sion
s fo
r th
ose
scre
ened
as
'hig
h ri
sk'.
Adv
erse
eve
nts
avoi
ded
(mot
or v
ehic
le c
rash
es)
The
pro
gram
me
wou
ld p
reve
nt r
ough
lyon
e de
ath
from
a a
lcoh
ol r
elat
ed m
otor
vehi
cle
cras
h. T
here
fore
in te
rms
ofsc
reen
ing
for
alco
hol p
robl
ems,
the
prog
ram
me
does
not
app
ear
cost
-ef
fect
ive.
At 5
% e
ffic
acy
the
cost
of
prev
enti
ng a
mot
or v
ehic
le c
rash
was
$120
70 a
nd c
ost o
f pr
even
ting
a de
ath
due
to a
mot
or v
ehic
le c
rash
is $
12m
illio
n
57
CHAPTER SEVEN SCREENING AND DETECTION
SUMMARY This chapter reviews the effectiveness and cost-effectiveness evidence relating to screeningfor and detection of problem drinking and alcohol abuse. The main findings are;• AUDIT is more effective in detecting at risk, hazardous or harmful drinking;• CAGE is superior in detecting alcohol abuse or dependence;• T-ACE and TWEAK are more sensitive and specific for screening pregnant women;• laboratory tests do not perform well as screening instruments;• telemarketing has been shown to be cost-effective in marketing screening and brief
intervention packages to GPs in Australia; and• specialist workers were shown to be cost-effective as screeners in a UK general hospital. Evaluating the performance of screening tests is hampered by the lack of an agreed goldstandard.
INTRODUCTION 7.1 This chapter concerns the screening instruments that are available for the detection ofproblem drinking, alcohol abuse and dependence and the laboratory tests that are availableeither to confirm such results or to monitor abstinence. The value of screening instrumentslies in the detection of people for whom a brief intervention or more intensive treatment maybe of benefit. Therefore, the important issue is the accuracy of the information that isprovided. The studies reviewed are summarised briefly in tables 7.1 (effectiveness) and 7.2(cost-effectiveness) at the end of the chapter.
SCREENING QUESTIONNAIRES
Types of intervention 7.2 A variety of questionnaires have been developed and the main instruments evaluatedin the literature are summarised in chart 7.1. Most have been developed for screeningpurposes although two are used to assess the extent of alcohol problems (S-MAST andSADD). There is some overlap in the type of questions asked, such as those relating to theneed to cut down on drinking or needing a drink to start the day (eye-opener). Othervariations on these instruments may also be in use.
58
Chart 7.1 Summary of main instruments in use AUDIT (Alcohol Use Disorders Identification Test)
10 questions which aim to detect hazardous drinking
CAGE (Cut down Annoyed Guilty Eye-opener) 4 questions that aim to detect alcohol abuse and dependence
Health Screening Survey and Questionnaire general questionnaire including alcohol. PRIME-MD (Primary Care Evaluation of Mental
Disorders) screens for mental health and alcohol use disorders.
S-MAST (Short Michigan Alcoholism Screening Test (also B-MAST)) 13 item self completion assessment instrument
SADD (Short Alcohol Dependence Data Questionnaire) 15 item self completionassessment of dependence severity.
T-ACE (Tolerance Annoyed Cut down Eye-opener) Trauma Scale 5 questions on alcohol related trauma TWEAK (Tolerance Worried Eye-opener Amnesia
Kut down) screens for alcohol problems in pregnant women
Effectiveness 7.3 The accuracy of screening instruments is assessed in terms of both sensitivity andspecificity. Sensitivity refers to the ability of the instrument to identify true positives (forexample, 80% sensitivity implies that 8 out of 10 people will be identified). Specificity refersto the accuracy in excluding true negatives (for example, 80% specificity implies that forevery 10 people without the condition of interest, 8 will be excluded). A good test is bothsensitive and specific but there is usually a trade off between these performance measures. 7.4 An overall assessment of performance is given by ROC curves, which plot sensitivityagainst 1 minus specificity. The area under the ROC curve (AUROC) provides a measure oftest performance with 1 equalling a perfect test and 0.5 indicating that the test provides nouseful information. Only one review reports these figures and they were only available fortwo studies (Bradley et al 1998). The AUROC score for CAGE was 0.84, for AUDIT therange was 0.86 – 0.94 and for TWEAK the scores were 0.89 - 0.90. 7.5 The performance of the screening questionnaires is very variable and some are betterat detecting certain levels of alcohol misuse than others. For general screening purposes,AUDIT is more effective in detecting at risk, hazardous or harmful drinking (sensitivity 51%-97%; specificity 78%-96%), whilst CAGE is superior for detecting alcohol abuse anddependency (sensitivity 43%-94%; specificity 70%-97%). These two tests perform betterthan other screening tests (Fiellin et al 2000). Screening performance also depends upon thechoice of cut-off point. A lower cut-off point will tend to increase sensitivity and reducespecificity.
59
Population groups 7.6 One review has considered the use of questionnaires with women (Bradley et al 1998).AUDIT, CAGE and TWEAK were the optimal test for detecting alcohol dependence inwomen but sensitivity in female populations may be lower using traditional cut-off points.CAGE was found to be more sensitive in samples of black women than white women.TWEAK appears to be optimal for detecting heavy drinking or alcohol abuse and dependencein racially mixed female populations. T-ACE and TWEAK are more sensitive and specificthan CAGE for screening pregnant women. The full Michigan Alcoholism Screening Test(MAST) has been found useful for psychiatric settings (Teitelbaum and Mullen 2000.)
Setting 7.7 Most screening takes place in outpatient and primary care settings. Comparisons ofscreening test performance across settings have not taken place.
Providers 7.8 Comparisons of different persons administering questionnaires were not reported inthe reviews. Some cost-effectiveness information is provided below (para 7.16).
Quality and relevance of evidence 7.9 The assessment of the screening instruments is limited by the lack of an agreeddiagnostic standard against which to confirm the screening results. A range of criterionstandards has been used in the studies reviewed and differences in the performance ofscreening instruments may be due to the choice of criterion standard (Fiellin et al 2000).
LABORATORY TESTS
Types of intervention 7.10 There is a range of routine and more specialised blood tests available to confirmevidence of problem drinking or alcohol abuse. The specific tests available for sustainedalcohol abuse are;
• GGT gamma-glutamyltransferase is an indicator ofliver injury
• CDT assay carbohydrate-deficient transferrin identifies men drinking 5 or more units per day for a year or more
60
Effectiveness 7.11 Laboratory tests are not useful in screening for alcohol related problems (Fiellin et all2000; NIAAA 2000). They have a role in monitoring the treatment of alcohol disorders. Onereview of studies comparing CDT assay with GGT concluded that in studies up to June 1998commercially available CDT assay tests were not significantly better than GGT as markers ofexcessive alcohol use (Scouller et al 2000).
COST-EFFECTIVENESS 7.12 The economic literature with respect to screening for alcohol problems is very limited.The sequence of events through screening, referral for treatment and eventually changes inpatient outcomes means economic analysis in this field is seldom undertaken. The keyeconomic study regarding screening centres on the marketing of the Drink-less package inNew Zealand. There is also limited UK evidence.
Drink-less 7.13 McCormick et al (1999) investigated cost-effective methods of encouraging generalpractitioners to take up screening and early intervention for problem use of alcohol in amarketing trial. The authors analysed the costs and consequences of marketing techniquesdesigned to encourage GPs to receive an early intervention and screening package for theproblem use of alcohol. An RCT of New Zealand GPs, comparing mail, telemarketing andpersonal marketing was employed for the ’Drinkless’ early intervention and screening packagedeveloped with the WHO collaborative study for early interventions for ’at risk’ alcoholconsumption. GPs in New Zealand were identified from a database. From a total of 369GPs, 186 were assigned to mail marketing, 87 to telemarketing and 96 to personal marketing.Of the 369, 40 were either ineligible or un-contactable. 7.14 The costs of the marketing exercise included promotional material, postage, telephonecharges, travel costs (time and transport), receptionist time and waiting time. Direct mailcosts per doctor were estimated at $5.11, telemarketing $2.92 and personal marketing $16.54.Outcomes were measured by the number of GPs willing to receive the package.Telemarketing appeared to be the most cost-effective means of persuading GPs to receive andemploy the Drink-less package. Sixty-four of the 87 GPs contacted agreed to receive thepackage. The cost per doctor receiving was $3.97. Direct mail cost $10 per doctor agreeingand personal marketing cost $20.36.
Quality and relevance of evidence 7.15 McCormick’s study shows a cost-effective means of disseminating information butinformation about how effective the Drink-less intervention is in practice is required. Little isknown about whether the GPs actually used the packages. A follow up would be needed asreceiving a package does not amount to using it, and thus health improvements could benegligible. More information on the treatment costs is provided in chapter 8.
61
Cost-effectiveness of alternative providers. 7.16 Tolley and Rowland (1991) investigated the cost-effectiveness of screening patientsfor alcohol problems at York District Hospital, UK. Over a 21-month period, doctors, nursesand a specialist worker screened orthopaedic and medical admissions to the Hospital. Thecosts of the intervention were calculated by using the mid-points of the salary ranges for therelevant grades and computing a cost for each screening based on the hourly rate of pay. Thecosts of screening were £0.10 for a nurse, £0.11 for a doctor and £0.15 for a specialist worker.As a percentage of admissions (positive screenings in parentheses), nurses screened 48%(7.8%), doctors 27% (9.8%) and the specialist worker 21% (12.5%). In terms of the lowestcost per positive screening, doctors cost £1.17, compared to £1.20 for the specialist workerand £1.29 for nurses. 7.17 The authors concluded that the specialist worker had a higher effectiveness ratedefined by the percentage of positive screenings made, whilst nurses managed to screen ahigher percentage of all admissions than doctors or the specialist. The authors conducted amarginal cost analysis based on the additional positive cases identified per 1000 screenings ofdifferent combinations of health care professionals delivering the interventions. Byemploying a specialist worker compared to a nurse, the specialist worker would identify anadditional 88 cases per 1000 admissions at a marginal cost per positive case identified of£0.56. However, it should be noted that other considerations are important. Hospitalmanagers may decide that the cost of employing a full time specialist is too great compared tothe additional cases detected. Furthermore it may mean that a specialist cannot devote anytime not screening to other duties. Nurses may be able to use any spare time moreproductively. The study provides some evidence as to the relative cost-effectiveness ofscreening for alcohol problems, but evidence is far from conclusive and likely to be affectedby staffing levels and other resource issues within the health care provider.
Quality and relevance of evidence 7.18 The crucial shortcomings of both studies are the outcomes employed. The initialscreening process identifies positive and negative screens, of which positives are referred forfurther treatment, yielding a further chain of events before successful health outcomes can bequantified. However, evaluations of screening programmes to date have only considered thefirst link, and the process through to patient outcomes is not covered by the current literature.
FURTHER RESEARCH 7.19 The available screening instruments appear to work well but evaluating theirperformance is hampered by the lack of an agreed diagnostic gold standard. Research toresolve this issue would be useful. Continuing research on the performance and role oflaboratory tests will be needed as they are developed. There is a lack of research relating tocomparisons of screening settings and providers.
62
Tab
le 7
.1Su
mm
ary
of S
cree
ning
and
Det
ecti
on E
ffec
tive
ness
Stu
dies
Rev
iew
ed A
utho
r(s)
and
Dat
e Se
arch
Stra
tegy
Incl
usio
n / E
xclu
sion
Cri
teri
a Q
ualit
yas
sess
ed N
umbe
r of
stud
ies
Tar
get
Gro
up M
ain
Find
ings
Bra
dley
KA
, Boy
d-W
icki
zer
J, P
owel
l SH
,B
urm
an M
L.
Alc
ohol
scre
enin
gqu
estio
nnai
res
inw
omen
: A c
riti
cal
revi
ew. J
AM
A 1
998;
280(
2): 1
66-7
1.
Yes
Stud
ies
incl
uded
com
pare
d a
brie
fal
coho
l scr
eeni
ngqu
estio
nnai
re w
ith a
nap
prop
riat
e cr
iteri
onst
anda
rd f
or h
eavy
drin
king
or
alco
hol
abus
e or
dep
ende
nce
in a
gen
eral
isab
le,
clin
ical
pop
ulat
ion
ofU
S w
omen
. Stu
dies
usin
g se
lf-
adm
inis
tere
dqu
estio
nnai
res
with
self
-rep
orte
dm
easu
res
of a
lcoh
olco
nsum
ptio
n. w
ere
excl
uded
.
Yes
9 st
udie
sev
alua
ting
8qu
estio
nnai
res
Wom
en T
he C
AG
E q
uest
ionn
aire
was
rel
ativ
ely
inse
nsiti
ve in
pred
omin
antly
whi
te f
emal
e po
pula
tions
. T
he T
WE
AK
and
AU
DIT
que
stio
nnai
res
have
per
form
ed a
dequ
atel
y in
bla
ck a
ndw
hite
wom
en, u
sing
low
er c
ut o
ff p
oint
s th
an u
sual
. R
efer
ring
wom
en to
all-
fem
ale
alco
hol t
reat
men
t pro
gram
s m
ay im
prov
edr
opou
t rat
es a
nd o
utco
mes
.
Fiel
lin D
A e
t al
Scre
enin
g fo
r al
coho
lpr
oble
ms
in p
rim
ary
care
: a s
yste
mat
icre
view
. Arc
hive
s of
Inte
rnal
Med
icin
e.20
00; 1
60(1
3): 1
977-
89.
Yes
Incl
uded
stu
dies
com
pari
ng a
scre
enin
g m
etho
d to
acr
iter
ion
stan
dard
,re
port
ing
perf
orm
ance
char
acte
rist
ics
and
carr
ied
out i
n a
prim
ary
care
set
ting
Yes
37 s
tudi
es V
ario
us A
UD
IT w
as m
ost e
ffec
tive
in d
etec
ting
at r
isk,
haz
ardo
us o
rha
rmfu
l dri
nkin
g (s
ensi
tivity
51%
-97%
; spe
cifi
city
78%
-96%
).C
AG
E w
as s
uper
ior
for
dete
ctin
g al
coho
l abu
se a
nd d
epen
denc
y(s
ensi
tivity
43%
-94%
; spe
cifi
city
70%
-97%
). T
hese
two
met
hods
perf
orm
ed c
onsi
sten
tly b
ette
r th
an o
ther
scr
eeni
ng te
sts.
The
con
clus
ions
are
lim
ited
by
the
lack
of
an a
gree
d cr
iter
ion
stan
dard
and
this
may
par
tly e
xpla
in c
onfl
ictin
g or
inco
nsis
tent
resu
lts.
Nat
iona
l Ins
titut
e on
Alc
ohol
Abu
se a
ndA
lcoh
olis
m, 1
0th
Q
uest
ions
abo
ut q
uant
ity a
nd f
requ
ency
of
drin
king
hav
e hi
ghse
nsiti
vity
in d
etec
ting
peop
le d
rink
ing
abov
e re
com
men
ded
limits
. P
atie
nts
may
und
erst
ate
thei
r dr
inki
ng.
63
Spec
ial R
epor
t to
the
US
Con
gres
s on
Alc
ohol
and
Hea
lth
June
200
0
CA
GE
is s
ensi
tive
and
spec
ific
in id
entif
ying
alc
ohol
abu
se a
ndde
pend
ence
but
mis
ses
som
e at
ris
k dr
inke
rs.
AU
DIT
has
sens
itiv
ity
of 5
0% to
80%
dep
endi
ng o
n th
e po
pula
tion
and
cut
off
scor
e. I
t may
mis
s bo
rder
line
risk
s an
d bi
nge
drin
kers
. L
onge
rqu
esti
onna
ire
may
be
less
sui
tabl
e as
pri
mar
y sc
reen
. H
ealt
hSc
reen
ing
Surv
ey a
nd Q
uest
ionn
aire
has
ade
quat
e se
nsiti
vity
and
spec
ific
ity
in p
rim
ary
care
set
ting
s. T
elep
hone
ass
iste
d co
mpu
ter
adm
inis
trat
ion
of P
RIM
E-M
D is
mor
e se
nsit
ive
than
fac
e to
fac
ead
min
istr
atio
n by
a c
linic
ian.
The
trau
ma
scal
e is
mor
e se
nsiti
veth
an la
bora
tory
test
s in
det
ectin
g pr
oble
m d
rink
ing
and
spec
ific
inru
ling
out p
robl
em d
rink
ing.
T-A
CE
and
TW
EA
K a
re m
ore
sens
itive
than
CA
GE
for
pre
gnan
t wom
en.
Lab
orat
ory
test
s ar
eno
t use
ful a
s pr
imar
y sc
reen
ing
tool
s. Sc
oulle
r K
et a
l Sho
uld
we
use
carb
ohyd
rate
-de
fici
ent t
rans
ferr
inin
stea
d of
gam
ma-
glut
amyl
tran
sfer
ase
for
dete
ctin
g pr
oble
mdr
inke
rs?
A s
yste
mat
icre
view
and
met
a-an
alys
is 2
000
Clin
ical
Che
mis
try;
46(
12):
1894
-190
2
Part
ially
repo
rted
Incl
uded
rep
orts
pres
entin
g or
igin
alda
ta f
rom
whi
chse
nsiti
vity
and
spec
ific
ity
of C
DT
coul
d be
cal
cula
ted
and
data
on
drin
king
beha
viou
r
Yes
110
stud
ies.
Men
,W
omen
In s
tudi
es p
rior
to J
une
1998
, res
ults
usi
ng c
omm
erci
ally
ava
ilabl
eC
DT
ass
ays
wer
e no
t sig
nifi
cant
ly b
ette
r th
an G
GT
as
mar
kers
of
exce
ssiv
e al
coho
l use
in p
aire
d st
udie
s. O
ther
ass
ay m
etho
dsap
pear
pro
mis
ing
but f
urth
er s
tudi
es a
re r
equi
red.
Tei
telb
aum
, L a
ndM
ulle
n, B
. T
heva
lidity
of
the
MA
STin
psy
chia
tric
set
tings
:a
met
a-an
alyt
icin
tegr
atio
n. J
ourn
al o
fSt
udie
s on
Alc
ohol
.20
00; 6
1 : 2
54-6
1
Yes
Incl
uded
stu
dies
eval
uatin
g th
e fu
llve
rsio
n of
MA
ST,
usin
g co
rres
pond
ing
cut-
off
scor
es,
cond
ucte
d in
aps
ychi
atri
c se
tting
and
repo
rtin
gsu
ffic
ient
dat
a.
Yes
9 st
udie
s Ps
ychi
atri
cpa
tient
s T
he w
eigh
ted
mea
n av
erag
e se
nsiti
vity
was
87.
7% a
nd th
ew
eigh
ted
mea
n av
erag
e sp
ecif
icity
was
68.
1%.
Thi
s su
gges
ts th
atM
AST
is le
ss e
ffec
tive
at s
cree
ning
out
thos
e w
ho d
o no
t hav
e an
alco
hol-
rela
ted
diso
rder
than
in id
entif
ying
thos
e w
ho d
o ha
vesu
ch a
dis
orde
r. F
ive
of th
e 9
stud
ies
eval
uate
d M
AS
T in
an
alco
hol t
reat
men
t set
ting
and
the
effe
cts
wer
e si
gnif
ican
tly
stro
nger
.
64
Tab
le 7
.2Su
mm
ary
of S
cree
ning
and
Det
ecti
on C
ost-
Eff
ecti
vene
ss S
tudi
es R
evie
wed
Stud
y T
ype
ofA
naly
sis
Popu
latio
n In
terv
entio
n O
utco
mes
Res
ults
McC
orm
ick
et a
l.E
ncou
ragi
ngge
nera
lpr
actit
ione
rs to
take
up
scre
enin
gan
d ea
rly
inte
rven
tion
for
prob
lem
use
of
alco
hol:
Am
arke
ting
tria
l.D
rug
and
Alc
ohol
Rev
iew
. 199
9; 1
8:17
1-7.
Part
ial
eval
uatio
nba
sed
onR
CT
369
NZ
GPs
. 18
6 G
Psas
sign
ed to
mai
lm
arke
ting,
87
tote
lem
arke
ting
and
96 to
pers
onal
mar
ketin
g.
Mai
l, te
lem
arke
ting
and
pers
onal
mar
ketin
g. T
heea
rly
inte
rven
tion
and
scre
enin
g pa
ckag
e w
as th
e’D
rink
less
’ pac
kage
deve
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65
CHAPTER EIGHT BRIEF INTERVENTIONS
SUMMARY This chapter reviews the effectiveness and cost-effectiveness evidence relating to briefinterventions used to treat problem drinking and alcohol abuse. The main findings are;• brief interventions are effective in reducing alcohol consumption for at least 12 months in
patients who are not alcohol dependent;• pooled results from clinical trials show a 24% reduction in alcohol consumption;• those who received the intervention were twice as likely to change their behaviour
compared with control groups;• brief interventions have fairly low costs and have been shown to be cost-effective in 3
economic studies;• using Scottish cost data the cost per life year lies in the range £1446 - £2628 assuming no
cost savings; and• if resource savings are taken into account brief interventions may provide net benefits. Savings from reduced future use of health care services need to be interpreted with care. It ismore likely that resources will be released for alternative uses than that financial savings willbe achieved.
INTRODUCTION 8.1 A brief intervention is a time-limited intervention focusing on changing patientbehaviour with respect to alcohol consumption through motivational counselling. There is amore extensive literature in this area than for many other interventions. The studies reviewedare summarised briefly in tables 8.7 (effectiveness) and 8.8 (cost-effectiveness) at the end ofthe chapter.
EFFECTIVENESS OF BRIEF INTERVENTIONS
Types of brief interventions. 8.2 A brief intervention has been defined as having 5 essential steps (Fleming andManwell 1999);
• assessment of drinking behaviour and feed back;• negotiation and agreement of goal for reducing alcohol use;• familiarisation of patient with behaviour modification techniques;• reinforcement with self help materials;• follow up telephone support or further visits.
66
8.3 The counselling strategy used in brief interventions has also been summarised asFRAMES (Miller and Rollnick, 1991 cited in O’Connor and Schottenfeld, 1998);
Feedback review problems experienced because of alcoholResponsibility patient is responsible for changeAdvice advise reduction or abstinenceMenu provide options for changing behaviourEmpathy use empathic approachSelf-efficacy encourage optimism about changing behaviour
8.4 The precise content of the brief interventions evaluated in trials is variable, however.In this section, reviews have been included if they refer to brief interventions, minimalinterventions or extended brief interventions. Brief interventions are mainly used to reducealcohol consumption in people drinking above recommended levels but who are notdependent. Brief interventions may also have a role in improving compliance with othertreatment regimens for alcohol dependent patients (Fleming and Manwell, 1999).
Effectiveness of brief interventions.
8.5 Most studies have found that brief interventions are effective in reducing alcoholconsumption for at least 12 months in patients who are not alcohol dependent, and whencompared with no intervention or usual care. A number of outcome measures are usedincluding levels of alcohol consumption, change from heavy to moderate drinking andbiochemical markers of alcohol consumption.
8.6 Formal meta-analysis of RCTs is difficult because of the variability in the content ofthe interventions, the population groups studied and the outcome measures used but this hasbeen attempted in 3 reviews (Freemantle et al 1993; Poikolaninen, 1999; Wilk, Jensen andHavighurst, 1997). The former pooled results from 6 trials and estimated the effect of briefintervention as a 24% reduction in alcohol consumption (95% CI; 18%-31%). The secondstudy analysed changes in alcohol consumption and concluded that there was no significanteffect for brief interventions in either men or women. Extended brief interventions wereeffective for women; in men the effect size was similar but not significant. The last studyanalysed the proportion of patients reducing or moderating their drinking and concluded thatthose receiving motivational interventions were twice as likely as controls to change theirbehaviour (Odds Ratio 1.95; 95% CI; 1.66-2.30).
8.7 Five of the 7 studies included by Poikolaninen and all of the studies included byFreemantle et al were also included in the 8 studies pooled by Wilk et al. These meta-analyses were conducted to very high standards but have used different measures ofeffectiveness to arrive at different conclusions.
67
Table 8.1 Pooled results from 8 RCTs of brief interventions.
Percentage moderating drinking Odds Ratio Number ofstudies
Treatment group Control group (95% confidence interval
All trials 44 28 1.95 (1.66 – 2.30) 8Quality trials 44 28 1.91 (1.61 – 2.27) 6
Females 50 27 2.42 (1.70 – 3.45) 3Males 46 29 1.90 (1.57 – 2.31 5
1 session 46 30 1.83 (1.46 – 2.28) 5>1 session 41 26 2.12 (1.66 – 2.70) 3
Outpatient 44 28 1.91 (1.61 – 2.27) 6Inpatient 48 27 2.41 (1.40 – 4.15) 2
Source Wilk et al 1997
8.8 Some studies that have found minimal differences between intervention and controlgroups achieved reductions in alcohol consumption in both groups (Fleming and Manwell,1999). This may be due to the research process drawing attention to drinking behaviour inthe control group. One study that found increases in alcohol intake, though not statisticallysignificant, is cited (Richmond et al, 1995 cited in Poikolainen, 1999). The same studyshowed a non-significant difference in the percentage moderating their alcohol use (Wilk,Jensen and Havighurst, 1997).
Population groups.
8.9 Brief interventions have been evaluated across a wide range of population groups, interms of demographic characteristics; men, women, and the elderly. However, the mostdifficult cases, in terms of their drinking behaviour are often excluded or may self-select outof studies at the recruitment or assessment stage. Brief interventions have not been shown tobe effective in pregnant women but this may be because of the high abstinence rates amongstthe women at the time of the intervention (Chang et al, 1999 cited in NIAAA, 2000).
Settings.
8.10 The majority of studies have been conducted in primary care settings. Briefinterventions have also been shown to be effective in inpatient settings, although the twostudies cited are rated as being of relatively low quality and conducted more than 10 years ago(Annti-Poika et al, 1988; Chick et al, 1985 cited in Wilk et al 1997). One small study hasalso shown an effect in a hypertension clinic (Maheswaran et al, 1992 cited in Wilk et al1997). Interventions in emergency room (A&E) settings have been effective in reducingalcohol consumption or securing referral into treatment (NIAAA, 2000).
68
Providers.
8.11 Doctors have delivered the brief interventions in the majority of studies. Nurses andhealth educators have also been effective in delivering brief interventions.
Intensity of intervention.
8.12 No significant difference in effectiveness was found between one session or more thanone session (Wilk et al, 1997). Although the meta-analysis by Poikolainen, 1999, appears tosupport extended brief interventions, the effect size for brief interventions was similar but didnot reach statistical significance.
Quality and relevance of the evidence.
8.13 Although the quality of the reviews is variable, overall they provide substantialsupport for the effectiveness of brief interventions in reducing alcohol consumption. Thereviews by Fleming and Manwell, Freemantle et al, Poikolainen and Wilk et al are the mostcomprehensive. The only study cited suggesting that brief interventions increase alcoholconsumption was not statistically significant. Potential for publication bias, that is the non-reporting of negative results, may still exist.
8.14 What is less clear is the generalisability of the results. The practitioners deliveringinterventions in research settings will be highly motivated and the effects may not becompletely replicated in routine practice. Some groups are clearly excluded from the scope ofthe intervention but the process of consent for research studies means that the participants inthe trial are self-selecting.
8.15 At least six of the reported trials were conducted in the UK and the effectivenessresults should be relevant to Scotland.
THE COST-EFFECTIVENESS OF BRIEF INTERVENTIONS
8.16 Brief interventions for alcohol treatment have been shown to be cost-effective inpublished research. One of the major contributing factors to this high level of cost-effectiveness is that these interventions are relatively cheap in terms of inputs. The inputs tocost-effectiveness investigations of brief interventions include three major stages. Patientsmust be screened for alcohol problems, assessed for suitability for treatment and then costs ofthe actual treatment quantified and valued. The major input for the former two categories isthe time of GPs plus any associated overheads and packages used. The costs of treatment willbe highly dependent upon the intervention in question.
Resource inputs
8.17 Few studies exist which document the cost-effectiveness of alcohol treatments insufficient detail as to be termed full economic evaluations. Fleming et al (2000) undertook a
69
cost-benefit analysis of physician advice regarding problem drinking, in the USA. Theauthors evaluated a programme of brief advice in general practice for drinking over thresholdlimits versus no treatment. The no treatment group received a booklet on general healthissues. The treatment group received the booklet and were scheduled to see their GP for thebrief intervention, including a workbook of current health behaviour, a review of theprevalence of problem drinking, a list of the adverse effects of alcohol, a worksheet ondrinking cues, a drinking agreement in the form of a prescription and drinking diary cards.The intervention was based on MRC protocols and consisted of two 15-minute appointmentsa month apart.
8.18 Patients received a follow up call from the clinic nurse two weeks after each GPmeeting. The clinic resources and patient time and travel required to deliver the interventionare summarised below.
Table 8.2 Resource inputs to a brief intervention - example
Clinic Resources Cost (1993 $)
Screening (8,962 patients) 30,736Assessment (1,481 patients) 3,844Primary intervention visit (392 patients) 10,266Follow up intervention visit (392 patients) 10,266Follow up phone calls 982Training 8,839Total clinic costs 64,933
Travel costs 3,646Lost work time 11,631
Total economic cost of study 80,210
8.19 Practitioner time was estimated by using salary cost for the duration of the event andadding 25% for overheads. Patient time for the intervention included waiting and travel time.The total treatment cost of the clinic was estimated at $64 933 (£44 230). The cost perpatient was $205 (£140) and total economic cost $80 210 (£54 640).
8.20 Wutzke et al (2001) investigated the question of whether brief interventions are cost-effective in reducing alcohol consumption. The direct costs of providing an alcohol treatmentprogramme in primary care were examined, including costs of treatment included marketingthe WHO's Drink-less package to GPs, training and support costs, and the cost of counsellingat risk drinkers.
8.21 Three support strategies were used, a control group (no initial training or on-goingsupport), a no support group (five minutes of initial training with no further contact orsupport), and a maximal support group (five minutes training plus alternate telephone andpersonal visits every two weeks). Marketing costs were taken from Gomel et al (1998) whoevaluated three strategies for recruiting GPs to the WHO Drink-less package, and found thetelemarketing option to be the most cost-effective. Cost of marketing was found to beAUS$2.16 per GP or AUS$5.35 per successful approach (not all agreed to use package).
70
8.22 Screening and counselling ’at risk’ drinkers followed strict protocols and took 5minutes of GP time, and the costs were taken from the Medicare Fee Schedule. Table 8.3shows the estimated average costs of delivering the intervention (1996 Australian dollars).Total costs for implementing the intervention nationally would be AUS$4.3 million for thecontrol strategy, AUS$7.5 million for the no support and AUS$12.8 million for the maximalsupport option. The cost per patient counselled in UK currency were £7.56 for the controlgroup, £6.80 for the no support group and £7.60 for the maximal support group.
Table 8.3 Intervention costs for Drink-less
Control No Support Maximal supportRecruitment 5.35 5.35 5.35Training 35.56 44.66 138.68Counselling 171.70 351.90 544.00Total cost per GP 212.61 401.91 688.03Number of people counselled per GP 10 21 32Cost per patient counselled 21.26 19.14 21.50
8.23 In a study of alcohol treatment in Sweden, Lindholm (1998) used results fromcontrolled trials showing short-term effectiveness combined with epidemiological studies ofalcohol and mortality links. In the model, if people reduce their drinking, life expectancy isexpected to increase. The differences in mortality between moderate and heavy drinkers arecalculated in terms of life years gained by switching drinkers from the 'high' to 'moderate'drinking level. Different relative risks and proportions changing from 'high' to 'moderate' arepresented to assess the impact on cost-effectiveness, based on cohorts of 'high' and 'moderate'drinkers. The intervention is a hypothetical programme of primary care advice to reduceindividual's drinking from a 'high' to a 'moderate' level. GP and nurse advice are modelled.
8.24 The costs per patient of the intervention are CAGE screening of 120ECU, GP visit of130 ECU, visit to district nurse of 40 ECU and GT tests costing 1 ECU. Yearly health carecosts per individual for moderate and heavy drinkers are presented, ranging from 700ECU(£432) (moderate 40-44 year olds) to 2 800ECU (£1 730) (Heavy, 65-69 year olds). Costs arediscounted at 5%.
Effectiveness of brief interventions: Alcohol consumption and health outcomes
8.25 The population in Fleming's study were patients aged 18-65 years attending routinegeneral practice appointments and reporting drinking above threshold limits (defined as menconsuming >14 drinks and women consuming >11 drinks per week), and comprised 482 menand 292 women. Health outcomes were based on self-reported alcohol consumption, at sixand twelve months, completing a timeline follow back. The average number of drinks in thepast seven days declined by 39.5% at six months and 40.0% at 12 months. Binge drinkingreduced by 49.1% (6 months) and 45.7% (12 months), which was significantly greater thanthe reduction in the control group.
8.26 Wutzke's estimates of post treatment consumption came from the WHO Phase 2 trialand outcomes were also presented as life years saved. Estimates from the WHO trial foundthat baseline alcohol consumption fell by 28% in the intervention group after treatment.
71
Potential deaths from alcohol related illnesses were then applied to the data to estimate thenumber of life years saved following implementation of the programme. The estimated lifeyears saved were 674, 1285 and 1972 in the control, no support and maximal supportstrategies.
Wider consequences
8.27 Wutzke’s work was based exclusively on costs and benefits to the health care providerand the individual patient. Fleming provided detailed treatment costs, and unit costs wereprovided for clinic costs for screening, assessment, primary visit, a follow up visit for patientsin the intervention group and clinic and training costs, using 1993 dollars. Fleming alsoestimated the wider economic costs from a societal perspective, including patient and healthcare costs and consequences, and cost savings to the legal system following treatment.Patient costs included travel and lost work time. However, health benefits to patients weremeasured in terms of drinking outcomes but not included in the aggregated results. Theexposition therefore resembles the cost-offset literature rather than a cost-effectiveness study.The estimated magnitudes of these wider economic costs are provided below.
Cost-effectiveness
8.28 In the Drink-less study, the average cost per life year saved was estimated to beAUS$645, AUS$581 and AUS$653 for the control, no support and maximal supportstrategies respectively, compared to ’do nothing’ baseline. Compared to the control, each yearof life costs $1,223 (£435) comparing minimal support with control and AUS$1,873 (£666)comparing maximal intervention with control. The results are based on the assumption thateffects last 10 years. A discount rate of 3% was applied to all costs and benefits occurring inthe future. The Drink-less package appears to offer a cost-effective means of reducingalcohol consumption and saving life years. Costs are very low compared to manyprogrammes currently in operation in Australia.
8.29 The wider economic costs and benefits in Fleming et al's analysis were not combinedwith health outcomes, hence are not strictly cost-effectiveness results. Savings in emergencyroom visits and hospital use were $195,448 (£133,134) compared to the control. However,whilst the cost of hospitalisations were significantly different from zero, the difference in thecost of emergency departments was not statistically significant. In terms of crime costs, adifference in the costs of legal events (substance abuse, theft, forgery, assault) was $18,963but not statistically significant. A difference of $209,108 for motor vehicle events was alsonot significant. Total savings of $228,071 also failed to satisfy significance testing (p=.14).The method of calculation was unclear.
8.30 Summing the total economic costs and benefits, the average benefit per subject was$1151 and the benefit-cost ratio 5.6:1 (or $56,263 in total benefit for every $10,000 investedin such programmes). However, it should be noted that such programmes may be subject todiminishing returns in a particular area and such benefit cannot be bought by continuallyinvesting sums of $10,000 into treatment as the greatest gains are likely to be exhausted first.However, as with many US studies, this claims to be a cost-benefit study but is actuallyanother cost-offset study, due to the omission of any valuation of patient health benefits
72
which are implicitly valued as zero. Some of the crime categories have few cases, makingcosts hard to extrapolate. Cost data are, on the whole, well presented although methodologiesare excluded in the case of criminal justice costs. Fleming found the total economic benefitof the brief intervention to be $423,519 (£288,490) (95% CI $35,947-$884,848), the resultsbeing significantly positive although the 95% confidence interval is particularly large.
8.31 In Lindholm's study, cost-effectiveness was estimated based on assumptions regardingthe proportion of drinkers changing from 'heavy' to 'moderate'. Based on 20% changing and arelative risk of mortality of heavy to moderate drinkers of 2, the 25 visit intervention cost200ECU (£123.50) per life year saved (LYS). With a relative risk of mortality of 1.25, with2% changing from heavy to moderate drinking status, the cost was 144,000ECU (£88,900) /LYS. If nurses give advice, as opposed to GPs, savings are greater than costs if effectivenessexceeds 10%. With the lowest effectiveness and relative risk figures, cost was 108,000ECU(£66,700) / LYS for the 25-visit and 20,000ECU (£12,350) / LYS for the 5-visit interventionprogramme.
8.32 Lindholm concludes that brief interventions delivered by GPs are cost-effective if thelasting treatment effect is about 1%. A 25-visit intervention is considered to be cost-effectiveif effectiveness is 2% and relative risk of mortality is greater than 1.5. Lower wages amongstnurses causes the cost-effectiveness of a nurse led intervention to be greater. However, theeffectiveness of a nurse-led intervention is unknown. Although the message is clear fromLindholm's results, the author points to potential bias in trials as participants are oftendifferent from non-participants. Furthermore, the results are sensitive to changing theparameters involved, as changes in the assumptions behind the model result in large changesin the cost-effectiveness ratios.
Quality and relevance of evidence
8.33 The studies outlined above illustrate brief interventions to be relatively cost-effective,due to fairly high levels of effectiveness and low costs. Fleming's study is effectively a cost-offset study, as individual health benefits are subsumed. The results are unlikely to havemuch relevance to Scotland. UK data do not tend to show the large benefit:cost ratios foundin the USA. It also must be remembered that the utilisation of health care in the USA showsvery different patterns to the UK, and the health care system is based on an insurance systemthat operates differently to the UK. Cost differences for health care interventions are alsolikely between the two countries.
8.34 A crucial difference between the studies is the way in which health outcomes are dealtwith. Outcomes are expressed in alcohol consumption in Fleming's work, whilst Wutzke andLindholm use life years saved. The advantage of the latter is that comparison with otherhealth care interventions is facilitated. Wutzke's study offers potential for modelling a similarstrategy in Scotland. Local costs could be estimated to replicate the study and assess thepotential cost-effectiveness for this package in Scotland.
8.35 Finally, it should be emphasised that generalising the results of economic evaluationsshould be undertaken with extreme caution. Evaluations carried out in insurance-basedhealth care systems and overseas where the prevalence and characteristics of alcohol relatedproblems are different to Scotland should not be considered as directly applicable to Scotland.
73
Incentives to use treatment and other health care services, and the impact of treatment onother costs, such as crime, should not be taken and applied directly to the Scottish scenario.
MODELLING OF RESULTS FOR SCOTLAND
8.36 The published literature on brief interventions can be used to estimate the cost-effectiveness of these interventions in the UK, by applying local costs to the main studyfindings. However, evidence is scarce as few papers include resource use and unit costs intheir analysis. Fleming et al (2000) conducted a cost-benefit analysis of brief GP advice withregard to problem drinking. They included health care costs and wider social costs using datafrom Project TrEAT, a randomised controlled trial. Based on a control group (n=382) and atreatment group (n=392), alcohol use, accident and emergency (A and E), hospital days andlegal events were recorded for the two populations.
Costs
8.37 In this simulation, local (UK) costs are applied to the resource use data to estimate thecost-effectiveness ratios that may be expected if the treatment programme was replicated inthe UK. Obviously these are only estimates and the results, especially treatmenteffectiveness, will be determined by particular characteristics of the population in the parentstudy. Table 8.5 shows the costs of the brief intervention programme, based on UK costs.GP costs (including overheads) of £1.92 per minute are used, whilst practice nurse time isestimated at £0.30 per minute (Netten and Curtis, 2000). It should be noted that all GP timeis costed using a 'higher bound' estimate including overhead costs for GP practice.
Table 8.5 Costs of the brief intervention programme, using UK costs 1999-2000
Unit costs:GP consultation cost (inc overheads) £1.92 / minutePractice nurse (£18/hour) £0.30 / minute
Training costs:1 hour GP plus 30 min 'booster' £172.801 hour practice nurse plus 1 hour consultation £36.00
Screening costs:5 mins with practice nurse £1.50
Assessment:5 mins with practice nurse £1.50
Cost of brief intervention15 mins with GP (£1.92 x 15 mins) £20.80
Follow up =15 mins with GP = (£1.92 x 15 mins) £20.80Two follow up phone calls (10 mins practice nurse) £3.00
74
8.38 The intervention requires that patients are screened and assessed before being given abrief intervention. Fleming’s study showed that 8,962 patients were screened and assessmentswere conducted for 1,481 patients to provide primary interventions for 392 patients.Therefore 22.8 screenings and 3.78 assessments are required for every patient receiving aprimary care intervention. The total intervention costs for one individual receiving a briefintervention are derived as follows:
costs for a total of 22.8 patients screened £34.20costs for a total of 3.78 patients assessed £5.67intervention of 15 minutes £20.80follow up also of 15 minutes £20.80two telephone follow ups5 minutes of practice nurse time each £3.00training costs per patient £2.27
total cost £86.74
Training costs will vary according to assumptions about workload. The figure used hereassumes 92 interventions per year. No other implementation costs have been included.
Consequences
Resource savings
8.39 In terms of health care utilisation, the table below shows the number of events perpatient in the previous 12 months at follow up. An average patient in the intervention groupexperienced 0.07 fewer A and E visits and 0.53 fewer hospitalised days compared to thecontrol group. Based on a cost of £44 per A and E attendance and £199 per hospital day(Information and Statistics Division 2000), the cost savings per patient are £3.08 (A and E)plus £105.47 (hospital days).
Table 8.6 Health care utilisation by intervention and control patients
Intervention ControlA and E visits 0.27 per patient 0.34 per patientDays hospitalised 0.32 per patient 0.85 per patient
(Source Fleming et al 2000)
8.40 Fleming's estimates of legal consequences include too few events to provide ameaningful comparison. However, if we look at motor vehicle events, there are 78 events inthe treatment group and 95 in the control at follow up. This converts to 0.20 per patient(Treatment) and 0.25 (control). The difference of 0.05 can be multiplied by the cost pervehicle crime of £890 (Home Office, 2000) to give a saving of £44.50 per individual.
75
Health outcomes
8.41 Fleming et al found the average reduction in alcohol consumption was 45.7 % at the12 month follow up. This is the same order of magnitude as the treatment groups in studiesincluded in the effectiveness reviews.
8.42 Based on Wutzke et al (2001) examining brief interventions in New Zealand, using abasic ’no support’ strategy, a total of 6,743 life years were estimated to be saved for apopulation of 204,587 counselled. This is 0.033 life years per patient.
Costs and consequences
8.43 If we assume the cost per patient of delivering a brief intervention is £86.74 and thatlife years saved are 0.033 then the cost of saving one life year is £2,628. (A lower estimatedcost of £1,446 per life year saved can be generated by modelling the intervention on the basisused in Wutzke.) In terms of cost offsets, based on Fleming's (2000) estimates, and usingScottish costs, the estimated health care savings from A and E attendances and hospitaliseddays avoided is £108.55. Therefore a cost saving of £21.81 per patient can be estimated. Inaddition, if vehicle crimes are included the saving increases sharply to £66.31. However,some care should be exercised in interpreting these results. The saving represents the valueof resources that are released but it is unlikely that financial savings of the same magnitudecould be realised.
Limitations of the simulation.
8.44 The simulation provides some outline figures against which actual policies could bemonitored. The figures for costs include an allowance for additional GP or nurse time forscreening and delivering the intervention. In practice, it is unclear how this additionalresource would be allocated but it is not assumed that these interventions are undertaken bysubstituting other primary care activity. The costs include some training element but do notinclude any direct implementation costs. A direct programme of implementation may berequired although marketing activities have in isolation a limited impact on take-up ofinterventions. In this simulation, the take-up does not alter the individual cost-effectivenessfigures as the costs (excluding training) vary directly with the number of brief interventionsundertaken. The direct costs of the intervention are low and therefore the results are highlysensitive to significant variations in assumptions. Indeed if health care cost savings arisefrom such interventions, as indicated in the Fleming et al study, there is potential for the NHSto save resources over time by implementing such interventions. However, there is no UKresearch on the size of such potential savings in a Scottish setting.
FURTHER RESEARCH
8.45 Brief interventions have been relatively well researched but evidence is required oftheir effectiveness when used routinely outwith a study setting. Specific interventions may berequired for the successful implementation of a brief intervention programme and the costsand effectiveness of implementation strategies should be evaluated. Any further studies on
76
brief interventions, per se, should focus on their longer-term effectiveness (most studies have6-12 months follow up) and the added effectiveness when combined with medication. Thereis also potential to use monitoring information from pilot schemes to improve the potentialeconomic simulations by substituting some actual costing data from these pilot schemes. Theimproved models could then be used to assess future schemes for their performance both interms of costs and outcomes with reference to this research.
77
Tab
le 8
.7Su
mm
ary
of B
rief
Int
erve
ntio
n E
ffec
tive
ness
Stu
dies
Rev
iew
ed
Aut
hor(
s) a
nd D
ate
Sea
rch
Stra
tegy
Incl
usio
n /
Exc
lusi
on C
rite
ria
Qua
lity
Ass
esse
dN
umbe
r of
Stud
ies
Rev
iew
ed
Tar
get G
roup
Mai
n Fi
ndin
gs
And
erso
n P
.E
ffec
tive
ness
of
gene
ral p
ract
ice
inte
rven
tions
for
patie
nts
with
harm
ful a
lcoh
olco
nsum
ptio
n.B
ritis
h Jo
urna
l of
Gen
eral
Pra
ctic
e.19
93; 4
3: 3
86-9
.
Not
repo
rted
.N
ot r
epor
ted.
Lim
ited
asse
ssm
ent
of q
ualit
y.
6 st
udie
sin
clud
ed.
Als
o in
clud
edw
as a
WH
Om
ulti-
cent
rest
udy.
Men
and
wom
en w
how
ere
heav
ydr
inke
rs.
The
res
ults
sug
gest
that
ver
y br
ief
advi
ce le
ads
to r
educ
tions
inal
coho
l con
sum
ptio
n of
25-
35%
and
red
uctio
ns in
the
prop
ortio
ns o
fex
cess
ive
drin
kers
of
arou
nd 4
5%.
The
stu
dies
pro
vide
som
eun
ders
tand
ing
of th
e ef
fect
ive
com
pone
nts
of b
rief
inte
rven
tion
s.Fi
rst,
the
targ
et o
f br
ief
inte
rven
tion
shou
ld b
e a
redu
ctio
n in
the
cons
umpt
ion
of a
lcoh
ol. S
econ
dly,
age
, soc
io-e
cono
mic
sta
tus
and
mar
ital s
tatu
s do
not
app
ear
to p
redi
ct o
utco
me.
Thi
rdly
, ini
tial l
evel
of c
onsu
mpt
ion
pred
icte
d ou
tcom
e, w
ith h
eavi
er d
rink
ers
in th
eW
HO
stu
dy r
educ
ing
thei
r al
coho
l con
sum
ptio
n by
a s
igni
fica
ntly
grea
ter
amou
nt a
t fol
low
-up
than
ligh
ter
drin
kers
, alth
ough
this
find
ing
was
not
rep
eate
d in
the
Oxf
ord
stud
y. F
ourt
hly,
in th
e W
HO
stud
y, a
mon
g th
ose
with
a lo
ng-t
erm
alc
ohol
pro
blem
, bri
efco
unse
llin
g w
orke
d be
st, w
hile
am
ong
thos
e w
ith
a re
cent
pro
blem
,si
mpl
e ad
vice
wor
ked
best
. T
his
sugg
ests
that
the
effe
ct o
f m
inim
alin
terv
enti
on is
enh
ance
d w
hen
the
pati
ent h
as e
xper
ienc
ed a
rec
ent
prob
lem
cau
sed
by a
lcoh
ol.
Fin
ally
, the
re is
gre
ater
evi
denc
e of
atr
eatm
ent e
ffec
t am
ong
men
than
wom
en.
Furt
her
wor
k in
this
are
ais
nee
ded,
and
it m
ay b
e th
at s
ex-s
peci
fic
inte
rven
tion
str
ateg
ies
shou
ld b
e ev
alua
ted.
Ash
ende
n R
et a
l.A
sys
tem
atic
revi
ew o
f th
eef
fect
iven
ess
ofpr
omot
ing
lifes
tyle
chan
ge in
gen
eral
prac
tice
. Fam
ily
Pra
ctic
e. 1
997;
14(2
): 1
60-7
6.
Yes
Eng
lish
lang
uage
only
.
Incl
uded
tria
ls o
flif
esty
le a
dvic
e in
GP
set
ting
with
rand
om a
lloca
tion
betw
een
expe
rim
ent
and
com
pari
son
grou
p
Yes
37 r
evie
wed
6 tr
ials
incl
uded
Men
and
wom
endr
inki
ngab
ove
safe
leve
ls
2 ou
t of
5 st
udie
s fo
und
sign
ific
ant c
hang
e in
alc
ohol
con
sum
ptio
n.E
ffec
t siz
e w
as g
reat
er f
or m
en th
an w
omen
. 3
out
of
6 st
udie
sfo
und
sign
ific
ant c
hang
e fr
om h
eavy
to m
oder
ate
drin
king
.P
ropo
rtio
n of
wom
en s
hift
ing
was
gre
ater
than
or
equa
l to
prop
ortio
nof
men
. 2
out
of
5 st
udie
s fo
und
sign
ific
antly
low
er G
GT
leve
ls.
Tri
als
incl
uded
4 f
rom
UK
, and
one
eac
h fr
om S
wed
en a
nd U
S.
Com
pari
son
grou
ps c
ould
be
no in
terv
entio
n, u
sual
car
e or
dif
fere
ntin
tens
ity o
f ad
vice
.
Bab
or, T
F et
al.
Not
Not
rep
orte
d.A
sses
sed
Poo
rly
The
dev
elop
men
t of
effe
ctiv
e, in
expe
nsiv
e, e
arly
inte
rven
tions
is s
till
78
Alc
ohol
-rel
ated
prob
lem
s in
the
prim
ary
heal
th c
are
setti
ng: A
rev
iew
of
earl
y in
terv
entio
nst
rate
gies
. Bri
tish
Jour
nal o
fA
ddic
tion.
198
6;81
: 23-
46.
repo
rted
.fo
r so
me
stud
ies.
repo
rted
inm
ajor
ity o
fin
clud
edst
udie
s.
in it
s ea
rly
stag
es.
Low
inte
nsity
, bri
ef in
terv
entio
ns h
ave
muc
h to
reco
mm
end
as th
e fi
rst a
ppro
ach
to th
e pr
oble
m d
rink
er in
the
prim
ary
care
set
ting.
Giv
en th
e te
ntat
ive
natu
re o
f m
any
of th
eco
nclu
sion
s dr
awn
from
this
rev
iew
, sys
tem
atic
res
earc
h on
ear
lyin
terv
entio
n sh
ould
be
give
n hi
gh p
rior
ity b
y bo
th n
atio
nal a
ndin
tern
atio
nal h
ealth
age
ncie
s.
Bie
n, M
ille
r an
dT
onig
an,
Bri
efin
terv
entio
ns f
oral
coho
l pro
blem
s: a
revi
ew 1
993
Add
ictio
n 88
: 315
-33
6
Not
repo
rted
Not
rep
orte
dY
es32
con
trol
led
stud
ies
Pro
blem
drin
kers
,he
avy
drin
kers
Bri
ef in
terv
entio
ns h
ave
been
sho
wn
to b
e ef
fect
ive
in f
acili
tatin
gre
ferr
al a
nd in
crea
sing
the
rate
of
retu
rn f
or tr
eatm
ent i
n al
l but
one
of 1
2 st
udie
s. S
igni
fica
nt r
educ
tions
in a
lcoh
ol u
se w
ere
foun
d in
7of
8 r
ando
mis
ed tr
ials
. W
ell p
lann
ed a
nd c
onsi
sten
tly a
dmin
iste
red
brie
f in
terv
enti
ons
can
have
an
impa
ct c
ompa
rabl
e to
that
of
mor
eex
tens
ive
coun
selli
ng.
Bri
ef in
terv
entio
ns p
rovi
ding
mot
ivat
iona
len
hanc
emen
t pri
or to
trea
tmen
t can
incr
ease
par
tici
pati
on r
ates
.
Din
h-Z
arr
T,
DiG
uise
ppi C
,H
eitm
an E
, Rob
erts
I. P
reve
ntin
gin
juri
es th
roug
hin
terv
entio
ns f
orpr
oble
m d
rink
ing:
A s
yste
mat
icre
view
of
rand
omis
edco
ntro
lled
tria
ls.
Alc
ohol
&A
lcoh
olis
m 1
999;
34(4
): 6
09-2
1.
Yes
Stud
ies
incl
uded
had
subj
ects
rand
omly
ass
igne
dto
exp
erim
enta
l and
cont
rol g
roup
s; a
ndin
terv
entio
nsde
sign
ed to
red
uce
or e
lim
inat
e al
coho
lco
nsum
ptio
n, o
r to
prev
ent i
njur
ies
orth
eir
ante
cede
nts;
and
if o
utco
me
mea
sure
s in
clud
edin
juri
es o
r th
eir
ante
cede
nts.
Yes
19 R
CT
sA
lcoh
olde
pend
ence
,al
coho
l abu
se,
or o
ther
prob
lem
drin
king
.
Thi
s sy
stem
atic
rev
iew
con
side
rs th
e ef
fect
of
a ra
nge
ofin
terv
entio
ns o
n in
juri
es a
nd d
eath
s. T
he r
esul
ts s
ugge
st th
attr
eatm
ent f
or p
robl
em d
rink
ing
may
red
uce
inju
ries
and
thei
ran
tece
dent
s, b
ut th
ere
wer
e a
num
ber
of m
etho
dolo
gica
l wea
knes
ses
and
effe
ct s
izes
wer
e of
ten
impr
ecis
e. B
ecau
se in
juri
es a
ccou
nt f
orm
uch
of th
e m
orbi
dity
and
mor
talit
y fr
om p
robl
em d
rink
ing,
fur
ther
stud
ies
are
war
rant
ed to
con
firm
thes
e ef
fect
s. T
he r
evie
w d
id n
otpr
ovid
e st
rong
sup
port
for
red
uced
alc
ohol
con
sum
ptio
n as
the
mec
hani
sm f
or in
jury
red
uctio
n.
Dru
mm
ond
DC
.A
lcoh
olin
terv
entio
ns: D
oth
e be
st th
ings
Not
repo
rted
.N
ot r
epor
ted.
Rev
iew
mai
nly
conc
erns
qual
ity o
f
Not
rep
orte
dN
ot r
epor
ted.
The
res
ults
of
RC
Ts
of b
rief
inte
rven
tions
are
not
gen
eral
isab
le to
grou
ps th
at a
re ty
pica
lly e
xclu
ded
from
stu
dies
eith
er e
xplic
itly
or b
yse
lf-s
elec
tion
, suc
h as
cas
es o
f se
vere
alc
ohol
dep
ende
nce,
conc
urre
nt m
enta
l illn
ess
or s
erio
us s
ocia
l pro
blem
s. F
ew s
tudi
es
79
com
e in
sm
all
pack
ages
?A
ddic
tion.
199
7;92
(4):
375
-9.
the
evid
ence
base
have
com
pare
d sp
ecia
list a
nd g
ener
alis
t int
erve
ntio
ns.
Man
ysu
bjec
ts d
o no
t im
prov
e an
d di
ffer
ence
s be
twee
n co
ntro
l and
inte
rven
tion
grou
ps a
re n
ot a
lway
s m
aint
aine
d. L
ittle
is k
now
n of
the
effe
ctiv
e in
gred
ient
s an
d th
e m
ost e
ffec
tive
met
hods
of
deli
very
.T
rial
s te
nd to
be
cond
ucte
d in
set
tings
with
mot
ivat
ed p
ract
ition
ers.
Rev
iew
s of
bri
ef in
terv
entio
ns h
ave
been
ove
rly
sele
ctiv
e, a
nd m
eta-
anal
ysis
in th
is a
rea
is p
robl
emat
ic.
Furt
her
rese
arch
is n
eede
d in
toth
e qu
estio
n of
whi
ch d
rink
ers
are
mos
t lik
ely
to b
enef
it fr
om w
hich
type
of
inte
rven
tion.
Flem
ing
MF,
Man
wel
l LB
. Bri
efin
terv
entio
n in
prim
ary
care
setti
ngs:
A p
rim
ary
trea
tmen
t met
hod
for
at-r
isk,
prob
lem
, and
depe
nden
t dri
nker
s.A
lcoh
ol R
esea
rch
and
Hea
lth. 1
999;
23(2
):12
8-37
Not
repo
rted
Not
rep
orte
dN
otre
port
ed13
tria
lsin
clud
edA
t ris
k,pr
oble
m a
ndde
pend
ent
drin
kers
.V
ario
uspo
pula
tion
grou
ps
Rev
iew
incl
uded
4 s
tudi
es e
ach
from
UK
and
US
, 2 f
rom
Sw
eden
,on
e ea
ch f
rom
Can
ada
and
Nor
way
and
one
cro
ss-n
atio
nal s
tudy
.B
rief
inte
rven
tion
is e
ffec
tive
with
at r
isk
and
prob
lem
dri
nker
s.E
ffec
t is
sim
ilar
for
men
and
wom
en a
nd a
cros
s ag
e gr
oups
(10
–30
% o
f pa
tient
s ch
angi
ng d
rink
ing
beha
viou
r).
Tw
o st
udie
sm
easu
red
hosp
italis
atio
n an
d fo
und
sign
ific
ant r
educ
tion
in le
ngth
for
inte
rven
tion
grou
ps.
Bri
ef in
terv
entio
ns m
ay a
lso
impr
ove
com
plia
nce
with
trea
tmen
t for
dep
ende
nt p
atie
nts
and
may
fac
ilita
tere
ferr
al in
to s
peci
alis
t tre
atm
ent f
or th
ose
who
fai
l to
resp
ond
to th
ebr
ief
inte
rven
tion.
Free
man
tle
et a
lB
rief
inte
rven
tions
and
alco
hol u
se19
93 Q
uali
ty in
Hea
lth C
are
2: 2
67-
273
Yes
Det
ails
in E
ffec
tive
Hea
lth C
are
Bul
letin
199
3.
Det
ails
inE
ffec
tive
Hea
lthC
are
Bul
letin
1993
7 R
CT
s of
brie
fin
terv
entio
nsve
rsus
asse
ssm
ent
only
con
trol
s;13
tria
ls o
fbr
ief
inte
rven
tions
vers
ussp
ecia
list
trea
tmen
ts
Hea
vydr
inke
rs,
Pro
blem
drin
kers
Met
a-an
alys
is o
f 6
of th
e 7
brie
f in
terv
entio
n st
udie
s pr
oduc
ed a
pool
ed r
esul
t of
24%
red
uctio
n in
alc
ohol
con
sum
ptio
n (9
5% C
I18
%-3
1%).
The
oth
er s
tudy
was
con
duct
ed w
ith h
yper
tens
ive
patie
nts.
The
stu
dies
com
pari
ng b
rief
inte
rven
tions
to s
peci
alis
ttr
eatm
ent w
ere
too
vari
ed to
be
pool
ed in
a f
orm
al m
eta-
anal
ysis
. In
gene
ral,
thes
e st
udie
s sh
owed
no
evid
ence
of
extr
a be
nefi
t fro
m m
ore
spec
ialis
t int
erve
ntio
ns.
How
ever
, whe
n br
ief
inte
rven
tions
are
unsu
cces
sful
, mor
e sp
ecia
list
trea
tmen
t may
be
effe
ctiv
e.
Fulle
r R
K, H
iller
-St
rmho
fel S
.A
lcoh
olis
mtr
eatm
ent i
n th
e
Not
repo
rted
.N
ot r
epor
ted.
Not
repo
rted
2 st
udie
s on
brie
fin
terv
entio
ns
Not
rep
orte
d.B
rief
inte
rven
tion
s w
ere
cons
ider
ed a
s pa
rt o
f a
wid
er r
evie
w o
ftr
eatm
ents
. B
oth
stud
ies
are
cove
red
by a
noth
er r
evie
w (
Fle
min
gan
d M
anw
ell)
80
Uni
ted
Stat
es: a
nov
ervi
ew. A
lcoh
olR
esea
rch
& H
ealt
h.19
99; 2
3(2)
: 69-
Kah
an M
et a
l.E
ffec
tive
ness
of
phys
icia
n-ba
sed
inte
rven
tions
with
prob
lem
dri
nker
s:A
rev
iew
. Can
adia
nM
edic
alA
ssoc
iatio
nJo
urna
l. 19
95;
152(
6): 8
51-9
.
Yes
.In
clud
ed R
CT
sex
amin
ing
the
effe
ctiv
enes
s of
inte
rven
tions
by
phys
icia
ns in
redu
cing
alc
ohol
cons
umpt
ion
amon
gpr
oble
m d
rink
ers
atte
ndin
g he
alth
care
fac
ilitie
s.T
rial
s in
volv
ing
subj
ects
atte
ndin
gal
coho
l tre
atm
ent
clin
ics
and
tria
lsde
liver
ed s
olel
y by
non-
phys
icia
n w
ere
excl
uded
.
Yes
.11
stu
dies
invo
lvin
g40
48 s
ubje
cts.
Pro
blem
drin
kers
. 3
stud
ies
pres
ente
dse
para
tere
sults
for
men
and
wom
en, 1
stud
y in
volv
edw
omen
onl
y.
The
tria
ls s
uppo
rt th
e us
e of
sho
rt-t
erm
inte
rven
tions
by
phys
icia
nsfo
r pa
tient
s w
ith d
rink
ing
prob
lem
s, a
lthou
gh, t
he r
esul
ts f
or w
omen
wer
e in
cons
iste
nt a
nd th
e tr
ials
did
not
pro
vide
con
vinc
ing
evid
ence
of r
educ
tions
in a
lcoh
ol-r
elat
ed m
orbi
dity
. E
ven
thou
gh s
hort
-ter
min
terv
entio
ns m
ay y
ield
onl
y m
odes
t red
uctio
ns in
alc
ohol
cons
umpt
ion,
thei
r pu
blic
hea
lth im
pact
is p
oten
tially
eno
rmou
s.F
urth
er r
esea
rch
is n
eede
d to
det
erm
ine
whi
ch p
atie
nts
are
best
suite
d fo
r sh
ort-
term
inte
rven
tions
, the
opt
imal
inte
nsity
of
trea
tmen
tan
d w
hich
com
pone
nts
of s
hort
-ter
m in
terv
entio
ns a
re m
ost
effe
ctiv
e. R
esea
rch
is a
lso
need
ed to
est
abli
sh w
hich
str
ateg
ies
are
effe
ctiv
e in
indu
cing
phy
sici
ans
to u
se s
hort
-ter
m in
terv
entio
ns.
Giv
en th
e ev
iden
ce f
or th
e ef
fect
iven
ess
of s
hort
-ter
m in
terv
entio
nsan
d th
e m
inim
al a
mou
nt o
f ef
fort
and
tim
e re
quir
ed, p
hysi
cian
s ar
ead
vise
d to
impl
emen
t the
se s
trat
egie
s in
thei
r pr
actic
e
Ket
ola
E e
t al
Eff
ecti
vene
ss o
fin
divi
dual
life
styl
ein
terv
entio
ns in
redu
cing
card
iova
scul
ardi
seas
e an
d ri
skfa
ctor
s 2
000
Ann
Med
32
: 239
-251
Yes
Incl
uded
RC
Ts
oflif
esty
lein
terv
entio
ns w
ithat
leas
t 60
subj
ects
,fo
llow
ed u
p fo
r at
leas
t 1 y
ear.
Yes
42 s
tudi
es o
fw
hich
3 w
ere
alco
hol
inte
rven
tions
and
4 w
ere
mul
tifac
tori
alw
ith
alco
hol
cons
umpt
ion
as a
n en
dpoi
nt
Hea
vydr
inke
rs,
Pro
blem
drin
kers
.
Tw
o of
the
alco
hol s
peci
fic
inte
rven
tion
s re
port
ed d
ecre
ases
inhe
avy
drin
king
(br
ief
inte
rven
tions
incl
uded
in o
ther
rev
iew
s).
The
se s
tudi
es r
epor
ted
no C
VD
end
poin
ts.
Onl
y on
e m
ulti
fact
oria
lst
udy
repo
rted
a s
tatis
tical
ly s
igni
fica
nt r
educ
tion
in a
lcoh
olco
nsum
ptio
n.
Mat
tick
RP
, Jar
vis
T. A
sum
mar
y of
reco
mm
enda
tion
sfo
r th
e m
anag
emen
tof
alc
ohol
prob
lem
s: th
equ
ality
ass
uran
ce in
Not
repo
rted
.N
ot r
epor
ted.
Not
repo
rted
.N
ot r
epor
ted
Not
rep
orte
dIn
situ
atio
ns w
here
ther
e is
no
time
avai
labl
e to
inte
rven
e w
ithex
cess
ive
drin
kers
, for
exa
mpl
e A
&E
, it i
s re
com
men
ded
that
leaf
lets
be
mad
e av
aila
ble
that
set
out
the
curr
entl
y ac
cept
ed“r
espo
nsib
le”
limits
for
alc
ohol
con
sum
ptio
n, a
nd li
st s
trat
egie
s fo
rcu
ttin
g ba
ck, a
s w
ell a
s ap
prop
riat
e co
ntac
t poi
nts
for
refe
rral
.W
here
a f
ew m
inut
es a
re a
vail
able
, bri
ef o
ne-t
o-on
e, f
ace-
to-f
ace
inte
rven
tion
s ar
e re
com
men
ded.
At a
min
imum
ther
e sh
ould
be
81
the
trea
tmen
t of
drug
dep
ende
nce
proj
ect.
Dru
g an
dA
lcoh
ol R
evie
w.
1994
; 13:
145
-55.
scre
enin
g an
d id
enti
fica
tion
of
exce
ssiv
e al
coho
l con
sum
ptio
n, c
lear
and
firm
adv
ice
to c
ut d
own
cons
umpt
ion,
a d
escr
ipti
on o
f th
esa
fe/r
espo
nsib
le le
vel o
f co
nsum
ptio
n an
d a
follo
w-u
p vi
sit.
For
drin
kers
with
mor
e se
vere
pro
blem
s, b
rief
inte
rven
tion
over
a f
ewse
ssio
ns (
1-5)
, is
reco
mm
ende
d. W
here
ass
essm
ent o
r pr
evio
usfa
ilure
s in
trea
tmen
t sug
gest
the
need
, lon
ger
out-
patie
nt in
terv
entio
nex
tend
ed o
ver
mul
tiple
ses
sion
s w
ill b
e re
quir
ed.
In-
patie
nt/r
esid
entia
l and
day
pat
ient
inte
rven
tions
for
the
mos
t
seri
ousl
y af
fect
ed a
nd d
epen
dent
indi
vidu
als
are
reco
mm
ende
d .M
cCra
dy B
SA
lcoh
ol u
sedi
sord
ers
and
the
Div
isio
n 12
Tas
kF
orce
of
the
Am
eric
anP
sych
olog
ical
Ass
ocia
tion,
Psy
chol
ogy
ofA
ddic
tive
Beh
avio
urs
2000
14(3
) : 2
67-2
76
Not
repo
rted
Pub
lishe
d st
udie
sre
port
ing
posi
tive
find
ings
Yes
62 s
tudi
es o
fal
l tre
atm
ent
type
s of
whi
ch13
wer
e br
ief
inte
rven
tions
Var
ious
Thi
s pa
per
revi
ews
alco
hol t
reat
men
t stu
dies
aga
inst
the
guid
elin
esof
the
Tas
k F
orce
. N
o tr
eatm
ent f
or a
lcoh
ol a
buse
or
depe
nden
ceha
d be
en r
ated
as
effi
caci
ous
by th
e T
ask
For
ce.
Thi
s st
udy
find
sth
at b
rief
inte
rven
tions
and
rel
apse
pre
vent
ion
do m
eet t
he c
rite
ria
but t
hat i
nsuf
fici
ent s
tudi
es h
ad b
een
publ
ishe
d w
hen
the
Tas
k Fo
rce
list w
as p
ublis
hed.
Mod
esto
-Low
e V
,B
oorn
azia
n A
.S
cree
ning
and
bri
efin
terv
entio
n in
the
man
agem
ent o
fea
rly
prob
lem
drin
kers
:In
tegr
atio
n in
tohe
alth
car
e se
tting
s.D
is M
anag
e H
ealth
Out
com
es. 2
000;
8(3)
: 129
-37.
Not
repo
rted
.N
ot r
epor
ted.
Not
repo
rted
.4
met
a-an
alys
is a
rein
clud
ed.
The
num
ber
oftr
ials
incl
uded
in 3
of
the
4m
eta-
anal
yses
are
repo
rted
tobe
32,
11,
and
12 w
hich
invo
lved
600
0,40
48, a
nd39
48 s
ubje
cts
resp
ectiv
ely.
Men
and
Wom
en w
hoar
e ea
rly
prob
lem
drin
kers
or
heav
ydr
inke
rs.
Bri
ef in
terv
entio
n re
duce
s dr
inki
ng a
mon
g ea
rly
prob
lem
dri
nker
s.A
lthou
gh m
ost e
arly
pro
blem
dri
nker
s do
not
go
on to
bec
ome
alco
hol d
epen
dent
, the
y ar
e a
legi
timat
e so
urce
of
conc
ern
due
toth
eir
sign
ific
ant n
umbe
rs a
nd th
e co
sts
invo
lved
in tr
eatin
g th
eir
heal
th a
nd s
ocia
l pro
blem
s. A
lcoh
ol d
epen
dent
dri
nker
s ar
e li
kely
tone
ed s
peci
alis
ed tr
eatm
ent (
e.g.
det
oxif
icat
ion,
reh
abili
tatio
n an
dA
lcoh
olic
Ano
nym
ous
mee
tings
) an
d ar
e un
likel
y to
ben
efit
from
brie
f in
terv
entio
ns.
How
ever
, if
the
indi
vidu
al’s
dri
nkin
g is
fou
nd to
be c
onsi
sten
t wit
h ha
zard
ous
or h
arm
ful d
rink
ing
or w
ith
alco
hol
abus
e, b
rief
inte
rven
tion
may
be
an e
ffec
tive
tool
. T
he W
HO
cro
sscu
ltura
l tri
al o
n br
ief
inte
rven
tions
fou
nd th
at h
eavy
dri
nker
s no
tre
port
ing
any
rece
nt a
dver
se c
onse
quen
ces
bene
fite
d fr
om a
mor
eex
tend
ed in
terv
enti
on w
here
as th
ose
who
had
exp
erie
nced
a r
ecen
tne
gativ
e co
nseq
uenc
e be
nefi
ted
from
the
inte
rven
tion
of s
hort
erdu
ratio
n. B
arri
ers
to im
plem
entin
g br
ief
inte
rven
tions
iden
tifie
din
clud
e: th
e ph
ysic
ian’
s fa
ilure
to s
cree
n pa
tient
s, la
ck o
f sk
ills
and
82
tim
e, o
rgan
isat
iona
l iss
ues,
lack
of
prof
essi
onal
rew
ard
and
lack
of
diag
nost
ic a
ids
for
alco
hol d
isor
ders
. Mor
alis
tic a
ttitu
des,
ster
eoty
pes
abou
t the
nat
ure
of a
lcoh
olis
m a
nd p
oor
com
mun
icat
ion
betw
een
phys
icia
ns a
nd n
on-p
hysi
cian
pro
vide
rs h
ave
also
impe
ded
prog
ress
in p
atie
nt id
entif
icat
ion
and
trea
tmen
t. D
espi
te th
ese
rese
arch
fin
ding
s, s
cree
ning
and
bri
ef in
terv
enti
ons
have
yet
to e
xert
a si
gnif
ican
t inf
luen
ce in
cli
nica
l pra
ctic
e.M
ulle
n P
D e
t al.
Am
eta-
anal
ysis
of
tria
ls e
valu
atin
gpa
tient
edu
catio
nan
d co
unse
lling
for
thre
e gr
oups
of
prev
enta
tive
hea
lth
beha
viou
rs. P
atie
ntE
duca
tion
&C
ouns
ellin
g. 1
997;
32(3
): 1
57-7
3.
Yes
Pub
lishe
d an
dun
publ
ishe
d st
udie
sm
easu
ring
the
effe
ctof
edu
cati
on o
rco
unse
lling
inte
rven
tions
.
Not
repo
rted
74 s
tudi
eson
ly 4
of
whi
ch d
ealt
wit
h al
coho
l
Var
ious
The
4 a
lcoh
ol s
tudi
es in
clud
ed w
ere
from
198
7 an
d 19
88 a
nd h
ave
been
incl
uded
in o
ther
larg
er r
evie
ws
repo
rted
in th
is s
ectio
n.
Nat
iona
l Ins
titut
eon
Alc
ohol
Abu
sean
d A
lcoh
olis
m,
10th
Spe
cial
Rep
ort
to th
e U
S C
ongr
ess
on A
lcoh
ol a
ndH
ealth
Jun
e 20
00.
Alth
ough
not
a s
yste
mat
ic r
evie
w, t
his
is a
n au
thor
itativ
e ov
ervi
ew o
fre
sear
ch, p
artic
ular
ly in
the
US.
The
sec
tion
on b
rief
inte
rven
tions
cite
s re
sults
fro
m B
ien
et a
l, 19
93 a
nd W
ilk e
t al 1
997.
Oth
ersp
ecif
ic f
indi
ngs
incl
ude
the
effe
ctiv
enes
s of
inte
rven
tion
s in
emer
genc
y ro
om s
ettin
gs a
nd in
spe
cifi
c po
pula
tions
(yo
ung
and
preg
nant
wom
en).
O’C
onno
r P
G,
Scho
ttenf
eld
RS.
Pat
ient
s w
ithal
coho
l pro
blem
s.N
ew E
ngla
ndJo
urna
l of
Med
icin
e. 1
998;
338(
9): 5
92-6
02.
Not
repo
rted
Not
rep
orte
dN
otre
port
edC
ites
3 tr
ials
and
2 ot
her
revi
ews
Hea
vy o
rex
cess
ive
drin
kers
Bri
ef in
terv
enti
ons
wer
e co
nsid
ered
as
part
of
a w
ider
rev
iew
of
trea
tmen
ts.
All
3 tr
ials
are
cov
ered
by
anot
her
revi
ew (
Fle
min
g an
dM
anw
ell)
and
the
2 re
view
s ar
e in
clud
ed h
ere
(Bie
n, M
iller
and
Ton
igan
, 199
3; W
ilk, J
ense
n an
d H
avig
hurs
t, 19
97.)
Poi
kola
nine
n K
.E
ffec
tive
ness
of
brie
f in
terv
entio
ns
Not
repo
rted
Incl
uded
stu
dies
on
gene
ral p
opul
atio
nor
GP
pop
ulat
ion
Not
repo
rted
7 tr
ials
incl
uded
Men
and
wom
en.
Pro
blem
Stud
y ef
fect
s w
ere
pool
ed u
sing
fix
ed e
ffec
ts m
odel
. C
hang
e in
alco
hol c
onsu
mpt
ion
was
not
sig
nifi
cant
for
men
or
wom
en f
or v
ery
brie
f in
terv
enti
ons.
E
xten
ded
brie
f in
terv
enti
ons
prod
uced
83
to r
educ
e al
coho
lin
take
in p
rim
ary
heal
th c
are
popu
latio
ns: A
met
a-an
alys
is.
Pre
vent
ativ
eM
edic
ine.
1999
;28
(5):
503
-9.
with
ran
dom
allo
catio
n, n
oin
terv
entio
n in
cont
rol g
roup
,al
coho
l int
ake
orG
GT
as
outc
ome
mea
sure
and
fol
low
up 6
-12
mon
ths.
drin
kers
and
heav
y dr
inke
rssi
gnif
ican
t red
ucti
on f
or w
omen
. A
vera
ge e
ffec
ts c
ould
not
be
relia
bly
estim
ated
for
oth
er p
oole
d da
ta.
Wal
itze
r K
S an
dC
onno
rs G
JT
reat
ing
prob
lem
drin
king
199
9A
lcoh
ol R
esea
rch
and
Hea
lth 2
3(2)
:13
8-43
Not
repo
rted
Not
rep
orte
dN
otre
port
edN
ot r
epor
ted
Pro
blem
drin
kers
with
low
leve
l of
depe
nden
ce
Thi
s pa
per
revi
ews
mod
erat
ion
trea
tmen
t for
pro
blem
dri
nker
s.D
rink
ing
redu
ctio
n ap
pear
s to
be
an e
ffec
tive
goa
l and
may
hav
epo
siti
ve b
enef
its
amon
g w
omen
. E
vide
nce
is c
ited
in s
uppo
rt o
fbi
blio
ther
apy
(sel
f-he
lp m
ater
ial)
, tel
epho
ne th
erap
y an
dm
otiv
atio
nal a
ppro
ache
s.
Wat
son
HE
.M
inim
alin
terv
entio
ns f
orpr
oble
m d
rink
ers:
A r
evie
w o
f th
elit
erat
ure.
Jou
rnal
of A
dvan
ced
Nur
sing
.199
9;30
(2):
513-
9.
Not
repo
rted
Not
rep
orte
dN
otre
port
ed13
stu
dies
incl
uded
Pro
blem
drin
kers
and
heav
ydr
inke
rs.
Var
ious
popu
latio
nch
arac
teri
stic
s
The
rev
iew
cov
ers
stud
ies
with
the
gene
ral p
opul
atio
n, m
edia
-re
crui
ted
stud
ies,
stu
dies
in g
ener
al p
ract
ice
and
acut
e ca
re s
etti
ngs.
Mos
t of
the
stud
ies
revi
ewed
are
incl
uded
in o
ther
rev
iew
s an
d no
form
al m
eta
anal
ysis
is c
arri
ed o
ut.
The
rev
iew
doe
s pr
ovid
e so
me
addi
tiona
l inf
orm
atio
n ab
out t
he m
etho
ds o
f th
e pr
imar
y st
udie
s an
dth
e co
nten
t of
the
inte
rven
tions
.
Wilk
AI
et a
l.M
eta-
anal
ysis
of
rand
omis
ed c
ontr
oltr
ials
add
ress
ing
brie
f in
terv
entio
nsin
hea
vy a
lcoh
oldr
inke
rs. J
ourn
al o
fG
ener
al I
nter
nal
Med
icin
e. 1
997;
12(5
): 2
74-8
3.
Yes
Eng
lish
lang
uage
only
Incl
uded
rand
omis
ed tr
ials
with
no
inte
rven
tion
in c
ontr
ol g
roup
s,sa
mpl
e si
ze a
t lea
st30
and
mot
ivat
iona
lin
terv
entio
n w
ithse
lf-h
elp
orie
ntat
ion
Yes
12 tr
ials
met
the
incl
usio
ncr
iteri
a
Hea
vy o
rpr
oble
mdr
inke
rs
Eig
ht o
f th
e st
udie
s co
ntai
ned
enou
gh d
ata
to b
e in
clud
ed in
the
form
al m
eta-
anal
ysis
. T
here
is c
onsi
dera
ble
over
lap
with
the
stud
ies
incl
uded
by
Free
man
tle e
t al a
nd P
oiko
lain
inen
. A
poo
led
odds
rat
iosh
owed
that
hea
vy d
rink
ers
rece
ivin
g a
brie
f in
terv
enti
on w
ere
alm
ost t
wic
e as
like
ly to
dec
reas
e an
d m
oder
ate
thei
r dr
inki
ngco
mpa
red
wit
h th
ose
who
rec
eive
d no
inte
rven
tion
(O
R 1
.95;
95%
CI
1.66
-2.3
). O
dds
ratio
s w
ere
high
er f
or m
ore
than
one
ses
sion
com
pare
d w
ith o
ne s
essi
on (
2.1
2 an
d 1.
83 r
espe
ctiv
ely)
, for
wom
enco
mpa
red
with
men
(2.
42 a
nd 1
.9)
and
for
inte
rven
tions
in in
patie
ntse
tting
s co
mpa
red
with
out
patie
nt s
ettin
gs (
2.41
and
1.9
1) b
ut n
one
of th
ese
diff
eren
ces
wer
e st
atis
tica
lly
sign
ific
ant.
84
Tab
le 8
.5Su
mm
ary
of B
rief
Int
erve
ntio
n C
ost-
Eff
ecti
vene
ss S
tudi
es R
evie
wed
Stud
yT
ype
ofA
naly
sis
Popu
latio
nIn
terv
entio
nO
utco
mes
Res
ults
Flem
ing
M, M
anw
ell
LB
. Bri
efin
terv
entio
n in
prim
ary
care
set
ting
s:A
pri
mar
y tr
eatm
ent
met
hod
for
at-r
isk,
prob
lem
, and
depe
nden
t dri
nker
s.A
lcoh
ol R
esea
rch
and
Hea
lth. 2
000;
23(2
):12
8-37
.
Cos
t-B
enef
itA
naly
sis
Patie
nts
aged
18-
65re
port
ing
drin
king
abov
e th
resh
old
limits
atte
ndin
gro
utin
e ge
nera
lpr
actic
eap
poin
tmen
ts (
men
cons
umin
g >
14dr
inks
and
wom
enco
nsum
ing
>11
drin
ks)
Bri
ef a
dvic
e in
gene
ral p
ract
ice
for
drin
king
over
thre
shol
dlim
its
Hea
lth
care
cos
t sav
ings
, cri
me
savi
ngs
Tot
al e
cono
mic
ben
efit
of th
e br
ief
inte
rven
tion
was
$423
,519
(95
% C
I $3
5947
-$88
4848
). S
avin
gs in
emer
genc
y ro
om v
isits
and
hos
pita
l use
= $
1954
48,
and
savi
ngs
in c
rim
e co
sts
= $
2280
71.
Ave
rage
bene
fit p
er s
ubje
ct =
$11
51.
Ben
efit
cost
rat
io =
5.6
:1
Lin
dhol
m L
. Alc
ohol
advi
ce in
pri
mar
yca
re: I
s it
a w
ise
use
of r
esou
rces
? H
ealt
hPo
licy.
199
8; 4
5:47
-56
Eco
nom
icev
alua
tion
Hyp
othe
tical
coho
rts
of ’h
igh’
and
’mod
erat
e’ d
rink
ers
in S
wed
en
A h
ypot
hetic
alin
terv
entio
n of
prim
ary
care
advi
ce to
red
uce
indi
vidu
al’s
drin
king
fro
m a
’hig
h’ to
a’m
oder
ate’
leve
l.G
P an
d nu
rse
advi
ce a
rem
odel
led.
Lif
e Y
ears
sav
ed.
Hea
lth
care
cos
tsa
ving
s -
how
ever
, the
ir r
ole
in th
em
odel
is n
ot f
ully
doc
umen
ted.
Cos
t-ef
fect
iven
ess
is e
stim
ated
bas
ed o
n th
eas
sum
ptio
ns r
egar
ding
the
prop
ortio
n of
dri
nker
sch
angi
ng f
rom
’hea
vy’ t
o ’m
oder
ate’
. B
ased
on
20%
chan
ging
and
a r
elat
ive
risk
of
mor
talit
y of
hea
vy to
mod
erat
e dr
inke
rs o
f 2,
the
25 v
isit
inte
rven
tion
cost
s20
0EC
U /
LY
S. W
ith R
R=
1.25
, 2%
cha
ngin
g th
eco
st is
144
000E
CU
/ L
YS.
If
nurs
es g
ive
advi
ce a
sop
pose
d to
GPs
, sav
ings
are
gre
ater
than
cos
ts if
effe
ctiv
enes
s ex
ceed
s 10
%.
Wit
h th
e lo
wes
tef
fect
iven
ess
and
RR
fig
ures
, cos
t is
1080
00E
CU
/LY
S fo
r 25
-vis
it an
d 20
,000
EC
U/L
YS
for
the
5 in
terv
entio
n pr
ogra
mm
e.W
utzk
e SE
et a
l. C
ost
effe
ctiv
enes
s of
bri
efin
terv
entio
ns f
orre
duci
ng a
lcoh
olco
nsum
ptio
n. S
ocia
lSc
ienc
e an
dM
edic
ine.
200
1;52
:863
-70
Eva
luat
ion
/ Sim
ulat
ion
Bas
ed o
n a
sim
ulat
ion
of th
eto
tal A
ustr
alia
npo
pula
tion
Bri
efin
terv
entio
nin
clud
ing
mar
ketin
g th
eW
HO
Dri
nk-
less
pac
kage
,ad
vert
ised
toG
Ps th
roug
hte
le-m
arke
ting.
Lif
e Y
ears
Sav
ed.
Est
imat
es f
rom
the
WH
O tr
ial f
ound
that
bas
elin
e al
coho
lco
nsum
ptio
n fe
ll by
28%
in th
ein
terv
entio
n gr
oup
afte
r tr
eatm
ent.
Pote
ntia
l dea
ths
from
alc
ohol
rel
ated
illne
sses
wer
e th
en a
pplie
d to
the
data
to e
stim
ate
the
num
ber
of li
fe y
ears
save
d. E
stim
ate
of 1
7 pe
r m
ale
and
11 p
er f
emal
e
Est
imat
ed li
fe y
ears
sav
ed =
674
, 128
5 an
d 19
72 in
the
cont
rol,
no s
uppo
rt a
nd m
axim
al s
uppo
rtst
rate
gies
. A
vera
ge c
ost p
er li
fe y
ear
save
d =
AU
S$64
5, A
US$
581
and
AU
S$65
3 fo
r th
e th
ree
stra
tegi
es, c
ompa
red
to ’d
o no
thin
g’.
Com
pare
d to
the
cont
rol,
each
yea
r of
life
cos
ts $
1223
com
pari
ngm
inim
al s
uppo
rt w
ith c
ontr
ol a
nd A
US$
1873
com
pari
ng m
axim
al in
terv
entio
n w
ith c
ontr
ol.
85
CHAPTER NINE DETOXIFICATION
SUMMARY
This chapter reviews the effectiveness and cost-effectiveness evidence relating todetoxification treatments. The main findings are;• benzodiazepines are the first choice therapy on the basis of safety and effectiveness;• outpatient treatment is safe and effective for mild to moderate symptoms;• a small study of home detoxification in Australia found better outcomes at lower cost
when compared with matched inpatient treatment; and• a US study found that outpatient treatment was significantly cheaper per successful
detoxification. Studies carried out in other health care systems need to be interpreted with caution. Moreinformation is needed about treatment settings, providers and intensity of treatment in a UKcontext.
INTRODUCTION 9.1 Detoxification refers to the period during which patients become alcohol free.Stopping drinking can produce a range of symptoms, collectively referred to as alcoholwithdrawal syndrome. Depending upon the severity of symptoms, the withdrawal processmay be managed on an inpatient or outpatient basis. The studies reviewed are summarisedbriefly in tables 9.1 (effectiveness) and 9.2 (cost-effectiveness) at the end of the chapter.
EFFECTIVENESS OF DETOXIFICATION
Types of intervention 9.2 A range of drug therapies has been assessed for use during detoxification. The broadcategories of drug interventions and their effects are:
Benzodiazepines decreased severity of withdrawal stabilization of vital signs prevention of seizures and delirium tremens Beta-blockers improvement in vital signs reduction in craving Alpha-agonists decreased withdrawal symptoms Antiepileptics decreased severity of withdrawal prevention of seizures
There are also reports of acupuncture as a treatment for withdrawal symptoms (Brewington etal, 1994; ter Riet et al, 1990).
86
Effectiveness 9.3 The literature supports the use of benzodiazepines as the first choice therapy on thebasis of safety and effectiveness (Fuller and Hiller-Sturmhofel 1999; O’Connor andSchottenfield 1998; Williams and McBride 1998). Antiepileptics are also effective in treatingmajor withdrawal symptoms but have serious potential side effects and higher cost (Williamsand McBride 1998). Other drug therapies have been reported as having some effect onwithdrawal symptoms but are considered to be adjunct treatments as they do not preventmajor withdrawal effects such as delirium tremens (O’Connor and Schottenfield 1998). 9.4 There are 2 small trials showing a positive effect of acupuncture on withdrawalsymptoms (Brewington et al 1994; ter Riet et al 1990).
Population groups 9.5 There are no reports of differential effects in different population groups.
Settings 9.6 Outpatient treatment is safe and effective for patients with mild to moderatesymptoms (Fuller and Hiller-Sturmhofel 1999; O’Connor and Schottenfield 1998).Completion rates may be lower and there is a greater risk of short-term relapse but outcomesat 6 months are not significantly different (Fuller and Hiller-Sturmhofel 1999).
Providers 9.7 No evaluations of alternative providers have been reported. One review considers thepotential role for nurses (Ryan et al 1999)
Intensity of treatment 9.8 Few studies have been carried out. Results from two studies of inpatient treatmentsuggest that reduction from 6 weeks to 4 weeks or from 28 days to 21 days had little effect onoutcomes (NIAAA 2000).
Quality and relevance of the evidence 9.9 The available trials have not assessed drugs on a common basis, making comparisonsacross trials difficult.
87
COST-EFFECTIVENESS
Home versus inpatient detoxification 9.10 Bartu and Saunders (1994) examined different settings for detoxification, comparinghome detoxification and inpatient detoxification in the treatment of alcohol problems.Twenty subjects on home detoxification were matched to 20 subjects with inpatientdetoxification. Subjects were interviewed between 9 and 22 months after detoxification tocompare client outcomes and costs. The study was from the perspective of the health careprovider and included 40 subjects at the Australian Alcohol and Drug Authority CommunityNursing Service detoxification facility. 9.11 In the home detoxification component, the client was visited at home by a nurse toensure that the home was suitable. Daily visits were provided for 3 to 4 days and then asfrequently as required for 10 days to monitor symptoms. The average number of visits was5.4 per client and the average duration was one hour. The comparison programme was aninpatient detoxification programme. The costs used in the study were inpatient days andhours of contact for home visits. One inpatient day cost $128, whilst an average inpatientdetoxification cost $1280 per client. An average home detoxification cost $154.44 (£55) perclient. 9.12 With respect to health outcomes, the home detoxification group fared better on selfreported drinking behaviour after treatment, and on quality of relationships and health status. 9.13 Home detoxification provides better outcomes at lower cost than inpatientdetoxification and is therefore considered a dominant programme. However, combining costsand effects would have been more informative in this study.
Quality and relevance of evidence 9.14 The relevance of this study outside the treatment population depends on clientcharacteristics and local costs. Costs are likely to resemble similar intensities in that home ischeaper than inpatient, but a generalised application must closely examine outcomes.Furthermore, a serious limitation of this study is the small sample size with just 20 patients ineach treatment. In addition, the wider consequences beyond health care costs should beconsidered in a more comprehensive economic analysis.
Inpatient versus outpatient detoxification 9.15 Hayashida et al (1989) compared the costs and effectiveness of inpatient andoutpatient detoxification for patients with mild to moderate alcohol withdrawal syndrome.The treatment population was 164 male veterans, of low socio-economic status, 87 in theoutpatient and 77 in the inpatient arm. Data were taken from a randomised prospective trialof patients prescribed either decreasing doses of oxazepam on the basis of daily clinic visits(outpatient treatment) or oxazepam, psychiatric and medical evaluation and initiation ofrehabilitation treatment (inpatient treatment). The health outcomes of the trial showed that at
88
6 month follow up 48% of inpatients and 46% of outpatients had remained sober (notsignificant), whilst 59% of outpatients and 51% of inpatients refrained from intoxication (nonsignificant). At one month follow up, 9% of the inpatient group compared with 0% of theoutpatient group reported being hospitalised. In terms of completion, 95% of inpatients and72% of outpatients completed treatment. 9.16 Costs were taken from direct cost surveys conducted for the study and from cost dataprovided from the fiscal service of the Medical Center. High and low estimates wereprovided based on different workload assumptions. The low estimates showed average costsof $3,319 (£2,260) (inpatient care), and $175 (£119) (outpatient). For the high estimates, theaverage cost of inpatient care was $3,665 (£2,497) and outpatient care was $388 (£264). Theauthors concluded that the cost per successful detoxification was significantly cheaper in theoutpatient group.
FURTHER RESEARCH 9.17 Studies that provide direct comparisons of different drug interventions are required.There are no studies of the added value for drugs that are seen as an adjunct to the maintherapy. More information is required about treatment settings, providers and intensity oftreatment in a UK context.
89
Tab
le 9
.1Su
mm
ary
of D
etox
ific
atio
n E
ffec
tive
ness
Stu
dies
Rev
iew
ed A
utho
r(s)
and
Dat
e Se
arch
Stra
tegy
Incl
usio
n /
Exc
lusi
on C
rite
ria
Qua
lity
asse
ssed
Num
ber
ofst
udie
s T
arge
tG
roup
Mai
n Fi
ndin
gs
Bat
el P
. The
trea
tmen
t of
alco
holi
sm in
Fra
nce.
Dru
g an
d A
lcoh
olD
epen
denc
e. 1
995;
39(S
uppl
1):
15S
-21S
.
RC
Ts
publ
ishe
dbe
twee
n19
60 a
nd19
93.
Not
rep
orte
d N
otre
port
ed.
Thi
spa
per
was
not
peer
revi
ewed
.
19 R
CT
s M
en a
ndW
omen
who
wer
eal
coho
lde
pend
ent
or p
robl
emdr
inke
rs.
The
eff
ecti
vene
ss o
f di
ffer
ent
phar
mac
othe
rapi
es w
as c
onsi
dere
din
the
sho
rt-t
erm
(<
10 w
eeks
), m
ediu
m-t
erm
(11
-16
wee
ks)
and
long
-ter
m (
26-5
2 w
eeks
). M
eta-
anal
yses
of
rand
omis
ed c
ontr
olle
dph
arm
aco-
ther
apeu
tic
stud
ies
of
pati
ents
tr
eate
d fo
r al
coho
l-re
late
d di
sord
ers
indi
cate
d th
at c
erta
in d
rugs
, su
ch a
s ci
talo
pram
,fl
uoxe
tine
, nal
trex
one,
and
aca
mpr
osat
e, a
ppea
r to
be
bene
fici
al in
the
trea
tmen
t of
alc
ohol
ism
, w
hile
zim
eldi
ne,
tetr
abat
ate,
L-d
opa,
and
vilo
xazi
ne
are
not.
T
he
resu
lts
for
lithi
um,
phen
ytoi
n,br
omoc
ript
ine,
apo
mor
phin
e, a
nd b
uspi
rone
wer
e m
ixed
. T
heid
entif
icat
ion
of a
lcoh
olic
pat
ient
s w
ho w
ill r
espo
nd t
o sp
ecif
icdr
ugs
will
rep
rese
nt s
igni
fica
nt p
rogr
ess
in th
is f
ield
. B
rew
ingt
on V
et a
lA
cupu
nctu
re a
s a
deto
xifi
catio
ntr
eatm
ent.1
994
Jou
rnal
of
Subs
tanc
e A
buse
Tre
atm
ent 1
1(4)
: 289
-307
Not
repo
rted
Not
rep
orte
d N
otre
port
ed 2
alco
hol s
tudi
es(s
ame
as te
rR
iet)
for
acup
unct
ure
and
3 us
ing
CE
S
T
he tw
o pl
aceb
o co
ntro
lled
stud
ies
on a
lcoh
ol a
buse
sup
port
the
ther
apeu
tic
effe
ct o
f co
rrec
t sit
e ac
upun
ctur
e. A
ddit
iona
lre
fere
nce
is m
ade
to r
epor
ts o
f sy
mpt
om r
elie
f as
soci
ated
with
acup
unct
ure.
Cra
nial
ele
ctro
stim
ulat
ion
has
been
eva
luat
ed in
3 s
mal
l stu
dies
inal
coho
lics.
Res
ults
are
rep
orte
d in
term
s of
eff
ects
on
moo
d st
ates
rath
er th
an d
rink
ing
beha
viou
r. Fu
ller
RK
, Hill
er-
Strm
hofe
l S. A
lcoh
olis
mtr
eatm
ent i
n th
e U
nite
dSt
ates
: an
over
view
.A
lcoh
ol R
esea
rch
&H
ealth
. 199
9; 2
3(2)
: 69-
77
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
Not
rep
orte
d N
otre
port
ed.
Thi
s pa
per
give
s an
ove
rvie
w o
f al
coho
l tre
atm
ent i
n th
e U
S.
For
mos
t pat
ient
s be
nzod
iaze
pine
s ar
e th
e dr
ug tr
eatm
ent o
fch
oice
for
wit
hdra
wal
sym
ptom
s. L
ower
dos
es c
an b
e us
ed if
dosa
ge is
con
stan
tly a
djus
ted
to s
ympt
om s
ever
ity.
Mild
sym
ptom
s do
not
req
uire
pha
rmac
othe
rapy
. M
oder
ate
sym
ptom
sca
n sa
fely
be
trea
ted
on a
n ou
tpat
ient
bas
is.
Out
patie
nt tr
eatm
ent s
houl
d no
t be
used
if s
ympt
oms
are
life
thre
aten
ing,
if p
atie
nts
have
oth
er s
erio
us m
edic
al c
ondi
tions
, are
suic
idal
or
hom
icid
al, h
ave
disr
upti
ve s
ocia
l cir
cum
stan
ce o
rca
nnot
trav
el d
aily
for
trea
tmen
t. O
utpa
tient
det
oxif
icat
ion
has
low
er c
ompl
etio
n ra
tes
and
incr
ease
d ri
sk o
f sh
ort-
term
rel
apse
.O
utco
mes
at 6
mon
ths
are
not s
igni
fica
ntly
dif
fere
nt f
or o
utpa
tient
and
inpa
tient
det
oxif
icat
ion.
Mat
tick
RP
, Jar
vis
T. A
Not
Not
rep
orte
d. N
ot N
ot r
epor
ted
Not
For
drin
kers
with
mor
e se
vere
pro
blem
s, b
rief
inte
rven
tion
over
a
90
sum
mar
y of
reco
mm
enda
tions
for
the
man
agem
ent o
f al
coho
lpr
oble
ms:
the
qual
ityas
sura
nce
in th
e tr
eatm
ent
of d
rug
depe
nden
cepr
ojec
t. D
rug
and
Alc
ohol
Rev
iew
. 199
4; 1
3: 1
45-5
5.
repo
rted
.re
port
ed.
repo
rted
few
ses
sion
s (1
-5),
is r
ecom
men
ded.
Whe
re a
sses
smen
t or
prev
ious
fai
lure
s in
trea
tmen
t sug
gest
the
need
, lon
ger
out-
patie
ntin
terv
entio
n ex
tend
ed o
ver
mul
tiple
ses
sion
s w
ill b
e re
quir
ed.
In-
patie
nt/r
esid
entia
l and
day
pat
ient
inte
rven
tions
for
the
mos
tse
riou
sly
affe
cted
and
dep
ende
nt in
divi
dual
s ar
e re
com
men
ded.
May
o-Sm
ith
MF
Pha
rmac
olog
ical
man
agem
ent o
f al
coho
lw
ithdr
awal
: a m
eta-
anal
ysis
and
evi
denc
eba
sed
prac
tice
guid
elin
e:A
mer
ican
Soc
iety
of
Add
ictio
n M
edic
ine
Wor
king
Gro
up o
nP
harm
acol
ogic
alM
anag
emen
t of
Alc
ohol
With
draw
al.
1997
Jour
nal o
f th
e A
mer
ican
Med
ical
Ass
ocia
tion;
278
:14
4-51
Yes
Hum
an s
ubje
cts
and
repo
rted
clin
ical
data
.
Yes
65 p
rosp
ectiv
eco
ntro
lled
tria
ls A
lcoh
olde
pend
ent,
heav
ydr
inki
ng
Ben
zodi
azep
ines
red
uce
wit
hdra
wal
sev
erit
y, r
educ
e in
cide
nce
ofde
liriu
m (
4.9
case
s pe
r 10
0 pa
tient
s; p
=0.
04),
and
red
uce
seiz
ures
(7.7
sei
zure
s pe
r 10
0 pa
tient
s; p
=0.
003)
. I
ndiv
idua
lisin
g th
erap
yw
ith w
ithdr
awal
sca
les
resu
lts i
n ad
min
istr
atio
n of
sig
nifi
cant
lyle
ss m
edic
atio
n an
d sh
orte
r tr
eatm
ent
(p<
0.00
1).
Bet
a-bl
ocke
rs,
clon
idin
e, a
nd c
arba
maz
epin
e im
prov
e w
ithd
raw
al s
ever
ity,
but
evid
ence
is
inad
equa
te t
o de
term
ine
thei
r ef
fect
on
delir
ium
and
seiz
ures
.
Phe
noth
iazi
nes
impr
ove
wit
hdra
wal
bu
t ar
e le
ssef
fect
ive
than
ben
zodi
azep
ines
in
redu
cing
del
iriu
m (
p=0.
002)
or
seiz
ures
(p<
0.00
1).
B
enzo
diaz
epin
es
are
suit
able
ag
ents
fo
ral
coho
l wit
hdra
wal
, wit
h th
e ch
oice
am
ong
diff
eren
t age
nts
guid
edby
dur
atio
n of
act
ion,
rap
idity
of
onse
t, an
d co
st.
Dos
age
shou
ldbe
in
divi
dual
ised
, ba
sed
on
with
draw
al
seve
rity
m
easu
red
byw
ithdr
awal
sca
les,
co-
mor
bid
illne
ss,
and
hist
ory
of w
ithdr
awal
seiz
ures
.
Bet
a-bl
ocke
rs,
clon
idin
e,
carb
amaz
epin
e,
and
neur
olep
tics
m
ay
be
used
as
ad
junc
tive
th
erap
y bu
t ar
e no
tre
com
men
ded
as m
onot
hera
py.
O
’Con
nor
PG
,Sc
hotte
nfie
ld R
S. P
atie
nts
wit
h al
coho
l pro
blem
s.N
ew E
ngla
nd J
ourn
al o
fM
edic
ine
1998
; 338
(9):
592-
602.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
Not
rep
orte
d M
en,
Wom
en,
Eld
erly
(ove
r 65
year
s).
Patie
nts
with
mild
sym
ptom
s do
not
req
uire
trea
tmen
t. M
ild to
mod
erat
e sy
mpt
oms
can
be tr
eate
d on
an
outp
atie
nt b
asis
. T
hose
with
mod
erat
e to
sev
ere
sym
ptom
s or
coe
xist
ing
prob
lem
s ar
eof
ten
best
trea
ted
as in
patie
nts.
Ben
zodi
azep
ines
are
the
safe
st a
nd m
ost e
ffec
tive
dru
g th
erap
y.O
ther
dru
g th
erap
ies
have
sho
wn
som
e ef
fect
on
wit
hdra
wal
sym
ptom
s (B
eta-
bloc
kers
, Alp
ha-a
goni
sts
and
antie
pile
ptic
s) b
utar
e be
st v
iew
ed a
s ad
junc
t tre
atm
ents
Pete
rs D
H, F
auld
s D
.T
iapr
ide:
A r
evie
w o
f its
phar
mac
olog
y an
d
Not
repo
rted
Not
rep
orte
d N
otre
port
ed 6
com
para
tive
stud
ies
ofT
iapr
ide
in
Not
wel
lre
port
ed.
Eth
nic
Com
para
tive
st
udie
s in
dica
te
that
th
e ef
fica
cy
of
Tia
prid
e is
sim
ilar
to
th
at
of
Dia
zepa
m,
Chl
ordi
azep
oxid
e an
dC
hlor
met
hiaz
ole.
In
the
larg
est
of t
he 3
tri
als,
adm
inis
trat
ion
of
91
ther
apeu
tic p
oten
tial i
n th
em
anag
emen
t of
alco
hol
depe
nden
ce s
yndr
ome.
Dru
gs. 1
994;
47(
6): 1
010-
32.
acut
e al
coho
lw
ithd
raw
al a
nd7
non-
com
para
tive
stud
ies.
3ra
ndom
ised
,do
uble
-blin
d,pl
aceb
o-co
ntro
lled
tria
lsas
sess
ing
the
effi
cacy
of
Tia
prid
e in
the
trea
tmen
t of
patie
nts
afte
rde
toxi
fica
tion.
grou
ps a
ndpe
ople
of
low
soc
ial
clas
s w
ere
incl
uded
inso
me
stud
ies.
Tia
prid
e fo
r 1-
3 m
onth
s re
sult
ed i
n an
inc
reas
e in
the
mea
n to
tal
time
that
pat
ient
s re
mai
ned
abst
inen
t (+
59 v
s. +
28 d
ays;
p =
0.00
2),
and
a de
crea
se i
n av
erag
e al
coho
l in
take
on
a he
avy
drin
king
day
(-2
5 vs
. –1
5 un
its;
p<0.
001)
whe
n co
mpa
red
with
plac
ebo
at 3
mon
ths
foll
ow u
p.
Tia
prid
e w
as a
ssoc
iate
d w
ith
are
duct
ion
in u
se o
f he
alth
care
res
ourc
es w
hen
com
pare
d w
ith
base
line.
T
he t
otal
dur
atio
n of
hos
pita
l vi
sits
dec
lined
by
5 da
ysov
er t
he t
reat
men
t pe
riod
, an
d 4.
7 da
ys d
urin
g po
st-t
reat
men
tfo
llow
-up
com
pare
d w
ith b
asel
ine
(p<
0.01
). T
iapr
ide
may
be
cons
ider
ed a
n al
tern
ativ
e to
Ben
zodi
azep
ines
or
Chl
orm
ethi
azol
e fo
r th
e tr
eatm
ent o
f pa
tien
ts a
t ris
k of
sev
ere
alco
hol w
ithd
raw
al, o
nly
if a
djun
ct th
erap
y fo
r ha
lluc
inos
is a
ndse
izur
es a
re a
vail
able
. H
owev
er, a
s id
enti
fyin
g th
ese
peop
le m
aypr
ove
diff
icul
t, th
e us
eful
ness
of
Tia
prid
e in
acu
te w
ithd
raw
al m
aybe
lim
ited.
Rya
n T
, Cas
h K
, Han
nis
D. N
urse
pre
scri
bing
and
in-p
atie
nt a
lcoh
olde
toxi
fica
tion.
Jou
rnal
of
Subs
tanc
e U
se 1
999;
4(3
):13
3-14
1.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
. T
his
pape
r re
view
s th
e po
tent
ial r
ole
of n
urse
s in
inpa
tient
deto
xifi
catio
n bu
t doe
s no
t rep
ort a
ny e
valu
atio
ns o
f in
crea
sing
the
nurs
ing
role
. A
lcoh
ol d
epen
dent
pat
ient
s re
quir
e a
com
preh
ensi
ve th
erap
euti
c ap
proa
ch a
nd c
onti
nuit
y of
car
e is
esse
ntia
l if
trea
tmen
t is
to h
ave
a si
gnif
ican
t im
pact
on
them
. The
mos
t obv
ious
adv
anta
ge o
f gi
ving
nur
ses
wor
king
in a
lcoh
olde
toxi
fica
tion
pres
crib
ing
righ
ts is
that
it w
ould
allo
w th
em to
offe
r ef
fect
ive
trea
tmen
t for
thei
r pa
tien
ts’
chan
ging
con
ditio
nsw
ith th
e m
inim
um a
mou
nt o
f de
lay.
Iss
ues
that
rem
ain
unre
solv
edat
pre
sent
incl
ude
whe
ther
the
cost
of
trai
ning
nur
ses
to u
nder
take
a gr
eate
r ro
le in
pre
scri
bing
wou
ld b
e of
fset
els
ewhe
re, e
ithe
r in
term
s of
doc
tors
’ ti
me,
red
uced
med
icin
es c
osts
or
even
pat
ient
satis
fact
ion.
The
eff
icac
y an
d de
sira
bilit
y of
suc
h ou
tcom
esw
ould
nee
d to
be
esta
blis
hed
prio
r to
nur
ses
taki
ng a
gre
ater
rol
ein
this
are
a. A
lso
clar
ific
atio
n of
who
wou
ld u
nder
take
the
trai
ning
of
nurs
es a
nd n
on-s
peci
alis
t doc
tors
, to
wha
t deg
ree
wou
ld th
ey b
e tr
aine
d an
d ho
w th
is w
ould
be
regu
late
d. te
r R
iet G
et a
l A
met
a-an
alys
is o
f st
udie
s in
to th
eef
fect
of
acup
unct
ure
onad
dict
ion
199
0 B
riti
shJo
urna
l of
Gen
eral
Yes
Incl
uded
stu
dies
of
hum
ans
addi
cted
toto
bacc
o, h
eroi
n or
alco
hol w
hich
had
are
fere
nce
grou
p.
Yes
22 s
tudi
es o
fw
hich
2 w
ere
rela
ted
toal
coho
l (sa
me
asB
rew
ingt
on e
t
Alc
ohol
depe
nden
t R
esul
ts f
or th
e tw
o al
coho
l stu
dies
are
des
crib
ed a
s po
sitiv
e. T
hest
udie
s di
d no
t hav
e hi
gh s
core
s on
met
hodo
logi
cal c
rite
ria
and
the
sam
ple
size
s w
ere
smal
l.
92
Pra
ctic
e 40
: 379
-382
Exc
lude
d st
udie
sus
ing
surf
ace
elec
trod
es o
r la
ser
acup
unct
ure.
al)
Will
iam
s D
, McB
ride
AJ.
The
dru
g tr
eatm
ent o
fal
coho
l wit
hdra
wal
sym
ptom
s: A
sys
tem
atic
revi
ew. A
lcoh
ol &
Alc
ohol
ism
199
8; 3
3(2)
:10
3-15
.
Yes
Stud
ies
wer
ein
clud
ed if
they
wer
e tr
ials
of
doub
le-b
lind
plac
ebo-
cont
rolle
dde
sign
.
Yes
14 s
tudi
es o
f 12
drug
s. I
nad
ditio
n 22
com
pari
son
tria
ls a
nd 1
5op
en tr
ials
did
not m
eet t
hein
clus
ion
crite
ria
Not
repo
rted
. A
ll 12
com
poun
ds i
nves
tigat
ed w
ere
repo
rted
to
be s
uper
ior
topl
aceb
o, b
ut t
his
has
only
bee
n re
plic
ated
for
Ben
zodi
azep
ines
and
Chl
orm
ethi
azol
e.
Fur
ther
res
earc
h us
ing
bett
er m
etho
ds i
sre
quir
ed to
allo
w c
ompa
riso
n of
dif
fere
nt d
rugs
in th
e tr
eatm
ent o
fal
coho
l wit
hdra
wal
sym
ptom
s. O
n th
e ev
iden
ce a
vail
able
, a l
ong-
acti
ng B
enzo
diaz
epin
e sh
ould
be
the
drug
of
firs
t cho
ice.
93
Tab
le 9
.2Su
mm
ary
of D
etox
ific
atio
n C
ost-
Eff
ecti
vene
ss S
tudi
es R
evie
wed
Stud
y T
ype
of A
naly
sis
Popu
latio
n In
terv
entio
n O
utco
mes
Res
ults
Bar
tu A
, Sau
nder
sW
. Dom
icili
ary
Det
oxif
icat
ion:
A c
ost
effe
ctiv
e al
tern
ativ
eto
inpa
tient
trea
tmen
t.T
he A
ustr
alia
nJo
urna
l of
Adv
ance
dN
ursi
ng. 1
994;
11(
4):
12-8
.
Eco
nom
ic E
valu
atio
n 40
sub
ject
s at
the
Aus
tral
ian
Alc
ohol
and
Dru
g A
utho
rity
Com
mun
ity N
ursi
ngSe
rvic
e de
tox
faci
lity
Hom
e de
tox.
Clie
nt v
isite
d at
hom
e by
nur
se to
ens
ure
hom
esu
itabl
e. D
aily
vis
its f
or 3
to 4
days
and
then
as
freq
uent
ly a
sre
quir
ed f
or 1
0 da
ys to
mon
itor
sym
ptom
s. A
vera
ge n
umbe
r of
visi
ts =
5.4
per
clie
nt a
nd a
vera
gedu
ratio
n w
as 1
hou
r. C
ompa
red
with
inpa
tient
det
ox.
Alc
ohol
con
sum
ptio
n H
ealth
out
com
es, h
ome
deto
x gr
oup
fare
d be
tter
on s
elf
repo
rted
dri
nkin
gbe
havi
our
afte
r tr
eatm
ent,
qual
ity o
fre
latio
nshi
ps a
nd h
ealth
sta
tus.
The
aver
age
cost
of
a ho
me
deto
x w
as$1
54.4
4 w
ith th
e hi
ghes
t cos
t clie
ntat
$33
0. A
vera
ge c
ost o
f in
patie
ntde
tox=
$128
0.
Hay
ashi
da M
et a
l.C
ompa
rati
veef
fect
iven
ess
and
cost
s of
inpa
tient
and
outp
atie
ntde
toxi
fica
tion
with
mild
-to
–mod
erat
eal
coho
l with
draw
alsy
ndro
me.
The
New
Eng
land
Jou
rnal
of
Med
icin
e. 1
989;
320(
6): 3
58-6
5.
Cos
t-O
ffse
t 16
4 m
ale
vete
rans
, low
soci
o-ec
onom
ic s
tatu
s(U
SA)
Oxa
zepa
m d
etox
ific
atio
n,ps
ychi
atri
c an
d m
edic
al e
valu
atio
nan
d in
itiat
ion
of r
ehab
ilita
tion
trea
tmen
t (in
patie
nt tr
eatm
ent)
.
Hea
lth
care
cos
ts a
ndhe
alth
out
com
es H
ealt
h ca
re e
ffec
ts: A
t 6 m
onth
follo
w u
p 48
% in
patie
nts
and
46%
of
outp
atie
nts
had
rem
aine
d so
ber
(not
sign
ific
ant)
. 59
% o
f ou
tpat
ient
s an
d51
% o
f in
patie
nts
refr
aine
d fr
omin
toxi
catio
n (n
on s
igni
fica
nt).
At
one
mon
th f
ollo
w u
p, 9
% o
f in
patie
ntco
mpa
red
with
0%
out
patie
nt g
roup
sre
port
ed b
eing
hos
pita
lised
. In
term
sof
com
plet
ers,
95%
of
inpa
tient
s an
d72
% o
f ou
tpat
ient
s co
mpl
eted
trea
tmen
t. H
igh
and
low
est
imat
esba
sed
on d
iffe
rent
wor
kloa
das
sum
ptio
ns.
Low
est
imat
es,
Ave
rage
cos
t, in
patie
nt=
$3,3
19,
outp
atie
nt=
$175
. H
igh
estim
ates
,av
erag
e co
st in
patie
nt=
$3,6
65 a
ndou
tpat
ient
=$3
88
94
CHAPTER TEN RELAPSE PREVENTION
SUMMARY This chapter reviews the effectiveness and cost-effectiveness evidence relating to relapseprevention. The main findings are;• psychosocial interventions can be effective and may almost double the percentage
achieving abstinence or controlled drinking compared with spontaneous remission rates;• adjunct use of Acamprosate or Naltrexone has been shown in small trials to reduce
relapse rates;• a large US study has shown health care cost-savings arising from psychosocial treatments;• studies in Belgium and Germany have demonstrated cost savings for adjunct use of
Acamprosate;• two US studies have shown outpatient treatment to be more cost-effective than inpatient
treatment;• two small studies on Behavioural Marital Therapy have produced opposite conclusions
regarding cost-effectiveness; and• using UK cost data, adjunct treatment with Acamprosate produces net resource savings
but this may not result in financial savings. More information is required on the precise content of psychosocial interventions. Savingsfrom reduced future use of health care services need to be interpreted with care.
INTRODUCTION 10.1 Relapse prevention programmes consist of a combination of psychosocial andpharmacological interventions aimed at maintaining abstinence or problem free drinkingfollowing detoxification. The studies reviewed are summarised briefly in tables 10.9(effectiveness) and 10.10 (cost-effectiveness) at the end of the chapter.
EFFECTIVENESS OF RELAPSE PREVENTION
Types of intervention 10.2 There are three main forms of psychosocial intervention (Fuller and Hiller-Sturmhofel, 1999):
• cognitive-behavioural therapy (CBT) is designed to help patients to identifyhigh risk situations for relapse and to develop coping strategies;
• motivational enhancement therapy (MET) aims to motivate patients to changebehaviour; and
• 12-Step Facilitation Therapy (TSF) is based on the AA approach and provides12 consecutive activities that should be achieved during the recovery process.
One review has considered the use of transcendental meditation (Alexander et al 1994).
95
10.3 Pharmacotherapy can be based on aversion therapy or anticraving therapy. Aversiontherapy has been available for more than 50 years and relies on an unpleasant reactionbetween the medication and alcohol. The most common aversive medication is disulfiram.Anticraving medications are a more recent form of therapy and fall into two categories.Opioid or opiate antagonists (such as naltrexone) act by blocking the pleasant effects ofalcohol, thus reducing the desire to drink. Acamprosate is another drug aimed at reducingcraving although the mechanism by which it achieves this effect is less clear. 10.4 Other drug therapies have been evaluated for effectiveness in relapse prevention.These are mainly drug treatments that affect mood states such as anxiety and depression andinclude lithium, benzodiazepines and SSRIs (selective serotonin reuptake inhibitors).
Effectiveness of relapse prevention Psychosocial interventions 10.5 Psychosocial interventions are considered to be effective. Although interventionshave not been subject to randomised trials, largely because of the problems of withholdinginterventions from controls, it is generally accepted that spontaneous remission (recoverywithout intervention) occurs in about 1/3 of cases (Babor, 1995 cited in Raistrick et al 1999).This provides a benchmark for judging the effectiveness of interventions. 10.6 The best evidence on effectiveness is drawn from a large US study, Project MATCH.1,726 patients were randomly assigned to receive CBT, MET or TSF. 952 patients had onlyreceived outpatient treatment; 774 patients were receiving outpatient aftercare followinginpatient treatment. Table 10.1 summarises the results across all interventions for thesegroups. Interventions were more effective in the group that had previously received inpatientcare but there had been no matching between the sample groups. The total percentageachieving abstinence or controlled drinking was 56% to 60% compared with an estimatedspontaneous remission rate of 33%.
Table 10.1 12 month follow up results Project MATCH
Abstinent Controlleddrinking
Relapse
Recruited from inpatient care 35% 25% 40%
Recruited from outpatient care 19% 35% 46%
Source: O’Connor and Schottenfeld 1998 10.7 Project MATCH found little difference in the overall effectiveness of the 3interventions. Short-term effectiveness was lower for MET (at 3 months) but longer-termresults were similar at 3 years. The main objective of Project MATCH was to investigate
96
whether matching patients to therapies could increase effectiveness but results in this areawere rather limited. 10.8 One review of family therapy found this to be effective (Edwards and Steinglass,1995). The impact of family therapy depended on the gender of the alcoholic, the investmentin the relationship and family support. Transcendental meditation has also been demonstratedto be effective in one review (Alexander et al 1994). Pharmacological interventions 10.9 There is some evidence that Disulfiram may reduce drinking frequency and amountdrunk but no evidence of an increase in abstinence rates (Garbutt et al 1999; Hughes andCook 1997). A recent review of supervised Disulfiram suggests that this may be moreeffective for selected patients (Brewer et al, 2000). 10.10 Both Naltrexone and Acamprosate have been shown to delay return to drinking.Short-term results for Naltrexone from small trials suggest that relapse rates may reduce byhalf (Table 10.2).
Table 10.2 Comparison of relapse rates for Naltrexone and placebo Naltrexone Placebo Study size Relapse rates at end oftrial (12 weeks)
23% 54% 70 patients
40% 80% 104 patients 35% 53% 97 patients 14% 52% As above but analysis of
compliant patients only
Source : Garbutt et al 1999 10.11 Most studies of Acamprosate have shown an increase in the number of alcohol freedays and higher abstinence rates at 6 months but this effect may diminish over time. Studieswith a longer intervention period (48-52 weeks) have shown more sustained effects.
Table10.3 Examples of outcomes for Acamprosate versus placebo Acamprosate Placebo Alcohol free days over 3months
57 days (higher dose) 52 days (lower dose)
34 days
Alcohol free days over 6months
61 days 43 days p=0.025
Median time to firstrelapse
45 days 15 days p value not cited
Rate of continuousabstinence at 6 months
20% 10% p=0.024
Rate of continuousabstinence at 12 months
11% 5% p=0.173
Source: Drug & Therapeutics Bulletin 1997
97
10.12 There is little evidence that other drug therapies are generally effective for reducing orpreventing alcohol use. SSRIs have a mild and transient effect in moderate drinkers but noeffect on alcohol dependent patients (Lejoyeux 1996; NIAAA 2000). However, it isimportant that co-existing psychiatric problems are appropriately treated. Treatingdepression, for example, improves outcomes for drinking regardless of the type ofantidepressant.
Population groups 10.13 The populations studied have tended to be determined by alcohol use characteristicsrather than any demographic characteristics. Results for specific groups have not beenreported. Drug interventions tend to exclude pregnant women.
Settings 10.14 Comparison of settings has not been carried out in any of the studies reviewed.Where reported, interventions have mainly been in outpatient settings.
Providers 10.15 Comparison of providers has not been carried out in any of the studies reviewed.
Intensity of treatment 10.16 None of the literature reviewed considered this issue in detail. Evidence from ProjectMatch suggests that more intensive treatments (CBT and TSF) have better short-termoutcomes than less intensive methods (MET) but longer-term outcomes are similar. Twotrials of Acamprosate found a significant difference in abstinence rates at 52 weeks following48-52 weeks treatment, and a significant difference remained at 104 weeks. This contrastswith studies of shorter-term interventions (6 months) where effects were eroded during followup. A statistical analysis of treatment studies found that more intensive treatments had higherabstinence rates (Monahan and Finney 1996).
Quality and relevance of the evidence 10.17 The main problem with the evidence on psychosocial interventions is the lack ofstandardisation in the interventions. The effectiveness depends on what is delivered and howit is delivered and this needs to be reproducible if the same results are to be achieved. 10.18 Trials of Naltrexone are mostly small but of good quality. The reported follow upperiods are short. There is poor reporting of the nature of the psychosocial interventions usedalongside most of the evaluations of drug treatments. Compliance with drug therapy is aproblem. Most studies report results on an intention to treat basis and thus the estimates ofeffectiveness are not compromised. However, drop out rates are fairly high in these research
98
studies and may be higher in routine care settings. This has implications for the overallimpact of intervention programmes.
COST-EFFECTIVENESS
Psychosocial interventions 10.19 Holder et al (2000) investigated the medical care costs prior to and following theinitiation of alcohol treatment in Project MATCH. In Project MATCH, alcoholics werevolunteer subjects in a study designed to administer three major forms of outpatientalcoholism treatment (TSF, CBT, and four sessions of MET) in a randomised clinical trial.The treatments were examined in relation to ten primary matching variables. Subjectsattended on average two-thirds of the scheduled sessions. Nonetheless, they significantlyreduced their drinking amounts and frequency of drinking from 25 days to 6 days per monthat one year following treatment. One third of the purely outpatient treatment group drankwithout bingeing (>33%), compared with one fifth (<20%) who abstained throughout the one-year follow-up. Thus, fairly low levels of high-quality outpatient treatment succeeded ingreatly reduced drinking among alcohol-dependent subjects for a substantial follow-upperiod. Only two of the primary matching variables were found to have significant effects,psychiatric severity and network support for drinking. 10.20 Holder et al investigated the medical and health care impacts of the MATCHtreatments. The authors presented the findings of a longitudinal study of before and aftertreatment costs for 279 patients from 430 project MATCH patients at two of the nineMATCH research units. The medical care costs used in this study were inpatient costs,outpatient costs and total medical costs. Medical care cost data were compiled fromhospitals, insurance companies and health care providers, with service providers located bythe use of self complete forms issued to trial participants. Holder et al’s findings showedtreatment costs to the health service were reduced, and that matching patient characteristics toalcohol treatments at intake can reduce health care costs. Table 10.4, taken from Holder et al,shows the findings in terms of client characteristics and healthcare cost savings.
Table 10.4 Clinical effectiveness and cost savings of MATCH treatments Level Comparison of
clinicaleffectiveness
Cost savings peryear
Total cost savingsover 3 years
Alcohol dependence High TSF<CBT $293 (TSF) $879 Low CBT>TSF $271 (CBT) $813 Psychiatric severity High CBT=MET $996 (CBT) $2,988 Low MET=CBT $1,305 (MET) $3,915 Network support fordrinking
High CBT=MET $614 (CBT) $1,842
Low MET=CBT $1,457 (MET) $4,371
From Holder et al (2000): Parentheses show the treatment which is most likely to producemedical cost savings)
99
10.21 The results show health care cost savings to be dependent upon the key patientcharacteristics of alcohol dependence, psychiatric severity and the level of network supportfor drinking. The MET treatment appears most likely to generate cost savings in patients withlow psychiatric severity and low network support for drinking, whilst for the most severepatients in these two groups, CBT generates greater savings. For patients with high levels ofalcohol dependence, the TSF treatment produces greater health care cost savings.
Pharmacological interventions Acamprosate 10.22 Annemans et al (2000) investigated the cost-effectiveness of acamprosate inmaintaining abstinence amongst weaned alcoholic patients. Costs of treating patients withacamprosate were compared to no pharmaceutical treatment over 24 months. Average costsof relapse were calculated from insurance data based on a Belgian survey among GPs. AMarkov model was used to model the movement of patients over time through monthlystages. Possible states were ambulatory follow-up, ambulatory detoxification,institutionalised detoxification and, after detoxification, institutionalised follow up, lost tofollow up and death. If there was no relapse, patients would stay in same state; if theyrelapsed they could either lapse or binge. Probabilities were put into the model fromliterature based evidence. Costs were applied to each of the states and probabilities computedfor patients moving between states. The results were taken from a randomised-controlledtrial of 448 weaned alcoholics. 10.23 Simulations were calculated from a 24-month run of the model. Patient outcome wasnot included in the article, although good cost information provides a breakdown of the mainconstituent cost components. Total expected cost for the acamprosate strategy is 211,986BEFcompared to 233,287BEF for the ’no treatment’ strategy. The authors concluded thatacamprosate was cost saving to the health care provider, yielding average net savings of22,000 BEF (£3,370) per patient over 24 months. However, the model had only six states, forsimplicity, although there could be many more complications. The results are sensitive to theprobability of relapse and under different conditions may not be cost saving. The authorsmost notably omit wider costs (e.g. productivity etc) and also health benefits. 10.24 Shadlich and Brecht (1998) investigated the incremental cost per additional abstinentalcoholic for adjuvant acamprosate compared to a standard care baseline. Outcome data weretaken from the PRAMA study, a randomised-controlled trial, and epidemiological data.Expert opinion and official and administrative statistics were used for cost data. Themodelling exercise used a decision tree analysis of a simulation scenario with 500,000alcoholics. The definition of 'alcoholic' was not made clear. RCT data were based onpatients satisfying five of the DSM-III-R criteria for alcohol dependence, with a meanduration of alcoholism of ten years. 10.25 The treatment regimen evaluated was adjunct acamprosate for 48 weeks in addition tostandard care. Both treatments took place after an alcohol detoxification and the patients hadto be completely abstinent for a minimum of 14 and maximum of 28 days before admissioninto the study. Some detoxification was inpatient based. The comparator was a treatment ofcounselling or psychotherapy according to the routine practices of the 12 participatingpsychiatric out-patient centres with placebo. Health outcomes were measured by abstinencein the medication free follow-up period, but exactly how this was measured was not defined.
100
In addition, adverse health effects of alcohol dependence syndrome were considered (alcoholpsychoses, alcoholic fatty liver, acute alcoholic hepatitis and alcoholic liver cirrhosis) butthese were only included in the analysis of health costs avoided. 10.26 The treatment costs showed additional medication costs of acamprosate for 48 weeksvalued at DM6.78 per day. This was the only active treatment cost valued. It was assumedthat costs of standard care were the same for both groups and therefore no information wasgiven. Health care costs were projected for four major health outcomes, psychosis,dependence syndrome, alcoholic hepatitis and alcoholic liver cancer, and measured by theprobability of events for the non-abstinent group from expert opinion and standard hospitalcosts. Total programme costs were estimated at DM 2,169,000 for 1000 patients, with overallcost savings to society of –DM 2602 (£822) per additional abstinent patient.
Quality and relevance of the evidence 10.27 The authors provide an interesting study that could be replicated using data fromScotland. There are issues about standard care and how acamprosate can be administered atthe ideal period when people have become first abstinent. However, the study fails to accountfor a number of potential benefits from treatment and main outcome is limited. Acamprosateis a therapy currently used in the UK. The Edinburgh clinic was one of the centres in theoriginal trials, although the results from the Scottish site did not suggest that there wereadditional benefits from the treatment.
Inpatient versus outpatient aftercare 10.28 McCrady et al (1986) examined the cost-effectiveness of partial hospitalisation versusinpatient settings after brief inpatient alcohol treatment. A population of alcoholics in need ofdetoxification or intensive inpatient care, and diagnosed as an alcohol abuser or alcoholdependent, were randomly assigned to partial hospitalisation (PHT) or inpatient treatment(EIP) after inpatient evaluation and / or detoxification. Partial hospitalisation was a hospitaldetoxification, followed by a period where the patient commuted to hospital from home for6.5 hours a day. For inpatient treatment, participants continued as inpatients but went into thesame programme as the partial patients. 10.29 The costs of treatment were taken from hospital bills, with attendances at hospitalcosted at an average visit cost, and hospitalisations costed at an average daily rate. Treatmentcosts included room and board and ancillary charges, whilst daily treatment program costsincluded work time missed and child care costs. The health care costs of hospitalisation were$183 per day, and of outpatient treatment were $35 per visit. Total treatment costs are shownbelow (table 10.5). Wider costs measured included legal problems, frequency and problemconsequences, income from missing work and child care during hospitalisation. Child carecosts were $1.50 per hour, based on 8 hours per day for PHT and 9.5 hours for EIP.
101
Table 10.5 Per Patient costs (1980 dollars) for PHT and EIP PHT EIP Inpatient $3164 $4851 Outpatient $687 $627 Rehospitalisation costs $1084 $954 Total treatment cost $4983 $6432
Source: McCrady et al (1986) 10.30 Total treatment costs were lower for the PHT group compared to the EIP group.Initial treatment costs were $1700 lower for PHT and outpatient and rehospitalisation costswere comparable. The PHT group was most likely to be hospitalised at other facilities. Unitcosts of improvement were defined by the difference between baseline and follow-upabstinent days divided by total treatment costs, to give abstinent days per $100 invested. Inthe PHT programme this was 5.4 days per $100 and for EIP, 4.2 days per 100. The treatmentcost per abstinent subject was $18,935 (PHT) and $21,637 (EIP). The total treatment cost perabstinent or moderate drinking subject was $9,966 (£6,788) (PHT) and $13,222 (£9,007)(EIP). 10.31 The authors concluded that partial hospitalisation offers a more cost-effectivealternative to the treatment of alcoholic patients when compared to inpatient treatment.However, 32% of clients did not respond to the extended follow up. There was also a heavyreliance on self-report data, with relatives, or other individuals nominated by the client,reporting more frequent drinking than clients. In terms of study generalisability, widerapplication will depend on local effectiveness data. If programmes are similarly effective, aless resource intensive intervention is likely to be more cost-effective. 10.32 Pettinati et al (1999) investigated whether patients had better outcomes with inpatientrather than outpatient treatment. A population of 93 inpatients and 80 outpatients with DSM-III-R diagnosis of alcohol dependence was evaluated at treatment entry to a private healthcaresetting. Both patient groups followed the same clinical programme based on a 12-stepprogramme of AA, individual, marital, family and group counselling in the intensivetreatment period of 4 weeks of inpatient and 6 weeks of outpatient care. Programmedifferences centred on amount of treatment hours and attendance at support groups.Inpatients attended therapy during the day and AA at evenings. Outpatients attended sessionsapproximately 1-2 evenings a week, AA meetings on the evenings that they did not attendtherapy sessions, and a family education programme during weekends. 10.33 Treatment costs were calculated from service billing and adjusted for geographic andinstitution specific charges. Wage losses and transportation costs to outpatient sessions werealso added. Effectiveness was defined by the probability of returning to drinking givenpsychiatric severity and/or number of drinking consequences at treatment entry. The averagecost per successfully completing inpatient was $9,014 (£6,140) and for an outpatient, $1,420(£967). This indicates inpatient treatment costs were approximately 6.5 times that ofoutpatient. The authors calculate a 'cost-effectiveness' ratio at three, six and 12 monthsfollow up as a ratio of inpatient:outpatient costs and find the ratios to be 4.5:1, 5.3:1 and 5.6:1respectively. The authors conclude that this is a modest 'cost-offset' effect.
102
Quality and relevance of the evidence 10.34 Much more meaningful cost-effectiveness results could have been illustrated bycombining the costs and outcomes in the more traditional way. The study is also confined toa group of patients in the higher socio-economic class brackets, located in a private healthcare setting, and also uses a non-random study technique. Furthermore, cost information isnot well presented and the value of the study is very limited.
Behavioural marital therapy 10.35 O’Farrell et al (1996a) published a cost-benefit and cost-effectiveness analysis ofbehavioural marital therapy (BMT) with and without relapse prevention (RP) sessions foralcoholics and their spouses, conducted using a population of male alcoholics at the VeteransAffairs Medical Center, USA. The authors addressed whether alcohol related health and legalcosts decrease in the 12 months after, compared with 12 months before, an outpatient BMTprogramme, and whether decreased legal and health costs exceed programme costs. Theadditional cost savings of the health and legal systems were calculated when RP is added toBMT. 10.36 After participating in behavioural marital therapy, 59 couples with an alcoholichusband were randomly assigned to receive 15 relapse prevention sessions over the following12 months. Costs were analysed retrospectively to calculate the health and legal costs atintake and follow up and differences between BMT and BMT plus RP. The study did notprovide details of how costs were derived but estimated $2,279 per abstinent subject in BMT,and $3,280 in the BMT plus RP group. O’Farrell et al estimate savings in health care andlegal system costs as a result of adding the RP component to BMT using a hospitalisation perdiem rate of $260.73, $43.54 per day for halfway house stays, $63.01 per day for jail stays. 10.37 In terms of value for money, BMT appears more cost-effective than BMT plus RP interms of percentage of days abstinent per $100 spent (7% improvement versus 4%improvement per $100 treatment costs). For BMT, the monetary costs of health and legalsystem utilisation are reduced by an average $4200 per patient, compared with $1,259average costs of treatment. Comparing BMT and BMT plus RP, the monetary value ofbenefits minus treatment costs were $4,189 (£2,853) and $1,725 (£1,175) respectively. 10.38 A similar study by Farrell et al (1996b) randomly assigned 36 married male alcoholicswho had started individual therapy to one of three treatments: counselling alone, counsellingplus BMT, or counselling with an interactional couples group. The interactional therapyencouraged the sharing of feelings and problem solving through discussion and verbal insightinto each couple's relationship. The BMT couples group included weekly homework andbehavioural rehearsal to promote sobriety through an Antabuse Contact and to increasepositive couple and family activities and teach communication skills. 10.39 The resources used to provide the interventions consisted of outpatient treatmentsessions, with per session costs taken from VA cost accounting information. The cost of anoutpatient mental health visit for alcohol dependence was taken from the Cost Distribution
103
Report at the VAMC (cost $54.55). No further details are presented. Table 10.6 summarisesthe results of the cost-benefit analysis of the treatments.
Table 10.6 Cost-Benefit results for single versus couples counselling Individual
Counselling plusBMT (n=10)
IndividualCounselling plus
Interactional (n=12)
Individual Counsellingonly (n=12)
Costs of treatment $857 $895 $450 Baseline Health and Legal costs $7821 $4877 $9579 Follow up Health and Legal costs $1140 $7124 $1988 Monetary benefit of reduced Healthand Legal costs
$6681 -$2248 $7581
Monetary benefits minus treatmentdelivery cost
$5824 -$3143 $7131
Benefit-to-cost-ratio 8.64 -2.82 20.77
10.40 The costs of hospital and alcohol treatment were taken from the Veterans Affairs costschedules and the number of visits was recorded by timeline follow back by patients. TheMassachusetts Department of Corrections provided the cost of average stays in jail. Costs ofdelivering treatments were deducted from the dollar reductions in utilisation to estimate thecost savings. The benefit to cost ratio computed then shows positive cost offsets where ratiosexceed unity. 10.41 By adding BMT or interactional couples therapy to the counselling, the number oftherapy sessions roughly doubled, as did the cost from about $450 for eight sessions to aboutsixteen at a cost of $900. The results showed that there were additional costs involved interms of health and legal costs when interactional couples therapy was added to individualcounselling, with a negative benefit-to-cost ratio. However, costs did fall for the BMT andindividual counselling only treatments. The authors point to the greatest reduction in costs asa result of the counselling only intervention, and close examination of the data shows that theincremental impact of adding BMT to individual counselling could have a very small, evennegative, marginal impact. 10.42 In terms of cost-effectiveness analysis, results are presented in units of outcome per$100 of programme expenditure. In terms of units of improvement in percent days abstinent,from pre-treatment to one year follow up, individual counselling plus BMT yields 5.4 daysimprovement per $100 invested, individual counselling plus interactional therapy yields 4.3days and individual counselling only generates 13.6. In terms of costs to produce onecontinually abstinent participant, for one year, counselling alone cost $1,350 (£920),counselling plus interactional therapy cost $3,580 (£2,440) and counselling plus BMT, $2,143(£1,460). The results suggest counselling alone to be the most cost-effective treatment.
Quality and relevance of the evidence 10.43 O'Farrell et al's results clearly show the consequences of treatment, but lack details ofthe costs of the interventions. The study results are also limited by the small sample sizes inthe treatments (n=12, n=12 and n=10). In addition, the study results should not begeneralised beyond the population in question. The participants were elderly Americans and
104
it is questionable whether the results would be replicated in a UK population with differentcharacteristics, in a very different health care system which operates with different costs.
MODELLING OF RESULTS FOR SCOTLAND 10.44 The following simulation draws on the work of Schadlich and Brecht (1998) andcombines data from the paper with local UK costs to estimate the potential cost-effectivenessof delivering a relapse prevention programme. However, since there are no health outcomedata, the simulation is limited to a cost-offset approach, whereby resource costs of avoidedadverse health outcomes are compared with the cost of treatment. 10.45 Schadlich and Brecht investigated the cost-effectiveness of acamprosate therapy inGermany. Acamprosate is provided for 48 weeks for 1000 patients as an adjunct to standardcare and compared with a placebo (1000 patients). The study examined trial evidence onadverse events as a consequence of treatment with acamprosate or standard care. In terms ofan incremental cost-effectiveness analysis the costs of the standard treatments should cancelout leaving the cost of the acamprosate treatment over and above standard care. In addition,the cost of an average GP consultation has been included for the prescribing of acamprosate(cost £18 for a 9.36 minute average consultation).
Costs 10.46 Campral EC has a cost of £24.95 (BNF, September 2000) for an 84 tablet pack.Based on a dose of 3 tablets a week, for 48 weeks, 12 packs would be required per patient at atotal cost of £299.40. The total cost of administering the treatment to 1000 patients is shownin table 10.7. The total additional cost of treating 1000 patients with adjunct acamprosate is£317,400.
Table 10.7 Costs for Acamprosate treatment in Scotland
Item Unit cost/patient Cost per 1000 patients GP consultations (9.36 minutes) £18 £18,000 Course of Campral EC £299.40 £299,400 Total £317,400
Consequences 10.47 Consequences of the two arms of the trial are listed in chart 10.1 in terms of alcoholicpsychoses (ICD291), alcohol-dependence syndrome (ICD303), acute alcoholic hepatitis(ICD571.1) and alcoholic liver cirrhosis (ICD571.2).
105
Chart 10.1 Adverse health consequences - Acamprosate trial
Consequences Adjuvant acamprosate 601 relapses ICD291 = 90 cases
ICD303 = 601 cases ICD571.1 = 150 cases ICD571.2 = 75 cases
1000 patients
1000 patients Consequences Standard care 827 relapses ICD291 = 124 cases
ICD303 = 827 cases ICD571.1 = 207 cases ICD571.2 = 103 cases
10.48 Using the data provided on mean length of stay in hospital and in rehabilitation units,the table 10.8 shows the estimated health care consequences as a result of standard care andadjuvant acamprosate treatment. Hospital costs are discounted at 6% per annum, based on theassumption of 10 years before the onset of alcoholic psychoses and alcoholic liver cirrhosis, 4years before alcohol dependence syndrome, and 5 years before acute alcoholic hepatitis. Theadverse consequences in the acamprosate treatment arm total £2,612,742 compared with£3,596,960 for the standard care arm.
Table 10.8 Resource consequences for Acamprosate and standard care
Number of cases / 1000patients
Hospital care Hospital cost perday
Total cost of treatment
ICD Acamprosate Standardcare
Mean days Acamprosate Standard care
291 90 124 18.02 124.52 201946.5 278237.4 303 601 827 16.69 176.64 1771821 2438097
571.1 150 207 18.61 166.64 465175.6 641942.3 571.2 75 103 18.61 124.52 173798.8 238683.7
2612742 3596960
Costs and Consequences 10.49 The incremental costs of acamprosate therapy and the incremental benefits oftreatment have been combined to estimate potential cost-offset effects. Treating 1000patients with acamprosate for 48 weeks, together with a single GP visit, costs approximately£317,400. The savings in terms of hospital care for adverse events avoided in theAcamprosate group are £984,218. This is a very conservative estimate as residentialrehabilitation savings are excluded from the calculations. However, some care should beexercised in interpreting this result. The saving represents the value of resources that arereleased and may be used to treat other patients; it is unlikely that financial savings of the
106
same magnitude could be realised. It should be noted that this analysis excludes any healthbenefits as a result of treatment.
Limitations of the modelling 10.50 The simulation is based on the cost of the “additional” treatment to standard care, i.e.that prescribing acamprosate as an adjunct requires an additional 2 GP consultations. Thesimulation suggests that the addition of this drug may result in net resource savings.However, there is a much smaller base of evidence for developing the type of modelillustrated in this section compared to that for brief interventions. The model is sensitive tothe assumptions made about the type of adverse events related to the relapse of treatment, i.e.patients return to heavy drinking. Fewer adverse events or lower Scottish costs per adverseevent may suggest a lower net benefit. However, it should be noted that there has been no“value” calculated for the health benefit (for example in terms of QALYs) that arise from thistreatment. The results therefore indicate that there is considerable scope for alcoholtreatments to have cost-effectiveness ratios well below current UK benchmarks and indeedsome may be resource saving
FURTHER RESEARCH 10.51 Studies examining the separate and combined effects of Naltrexone and Acamprosateare reported to be underway. Optimal treatment length also needs to be examined and longer-term follow up is required. Better studies of the separate and combined effects ofpsychosocial and pharmacological interventions are required as existing studies have notdescribed clearly the content of the psychosocial intervention. There is scope to developeconomic model using clinical data from the UK for wider simulations than the outline modelused in this chapter. Such models combining clinical effectiveness data, data on adverseevents of continued patterns of harmful drinking and local cost data could be used to comparedifferent alcohol treatments, the impact of expanding expenditure on alcohol treatment or thepotential for new drug treatments such as Naltrexone and Acamprosate combinations.Collecting more routine data from existing programmes could also be used to monitorexisting treatments against research expectations.
107
Tab
le10
.9Su
mm
ary
of R
elap
se P
reve
ntio
n E
ffec
tive
ness
Stu
dies
Rev
iew
ed A
utho
r(s)
and
Dat
e Se
arch
Stra
tegy
Incl
usio
n /
Exc
lusi
onC
rite
ria
Qua
lity
Ass
esse
d N
umbe
r of
Stud
ies
Rev
iew
ed
Tar
get
Gro
up M
ain
Find
ings
Aca
mpr
osat
e fo
r al
coho
lde
pend
ence
? D
rug
&T
hera
peut
ics
Bul
letin
199
7;35
(9):
70-
2.
Not
repo
rted
. St
udie
s in
clud
edw
ere
doub
le-
blin
d, p
lace
bo-
cont
rolle
dcl
inic
al tr
ials
.
Not
repo
rted
4 sh
ort-
term
tria
ls a
nd 3
long
er tr
ials
Not
repo
rted
. In
pa
tient
s w
ith
alco
hol
depe
nden
ce
who
ha
ve
unde
rgon
ede
toxi
fica
tion,
Aca
mpr
osat
e ta
ken
for
1 ye
ar w
ith r
ehab
ilita
tive
psyc
hoso
cial
th
erap
y in
crea
ses
the
likel
ihoo
d of
co
mpl
ete
abst
inen
ce o
r th
e nu
mbe
r of
day
s on
whi
ch n
o al
coho
l is
dru
nk,
duri
ng th
e tr
eatm
ent p
erio
d. B
enef
its m
ay c
ontin
ue f
or u
p to
1 y
ear
afte
r st
oppi
ng tr
eatm
ent,
alth
ough
whe
ther
the
bene
fits
con
tinue
into
a se
cond
yea
r is
not
kno
wn.
T
he d
rug
shou
ld o
nly
be g
iven
in
com
bina
tion
with
co
unse
lling
, w
hich
m
eans
th
at
the
trea
tmen
tsh
ould
nor
mal
ly b
e in
itiat
ed a
nd o
vers
een
by s
peci
alis
ts.
Ago
sti V
. The
eff
icac
y of
cont
rolle
d tr
ials
of
alco
hol
mis
use
trea
tmen
ts in
mai
ntai
ning
abs
tinen
ce: a
met
a-an
alys
is. I
nter
natio
nal
Jour
nal o
f th
e A
ddic
tions
1994
; 29(
6): 7
59-7
69
Not
repo
rted
infu
ll
Incl
uded
stu
dies
with
rand
omis
atio
n,co
ntro
l gro
up,
labo
rato
ry te
st o
rot
her
valid
atio
nof
rep
orte
dal
coho
l use
and
mea
sure
s of
abst
inen
ce r
ates
.
Not
repo
rted
15 s
tudi
esco
veri
ng a
rang
e of
psyc
hoso
cial
and
phar
mac
o-lo
gica
lin
terv
entio
ns.
Alc
ohol
depe
nden
t or
clin
ical
lysi
gnif
ican
tal
coho
lre
late
dpr
oble
ms
Rep
orts
odd
rat
ios
(lik
elih
ood
of a
bstin
ence
com
pare
d w
ith c
ontr
ol)
for
stud
ies
with
12
mon
th, 6
mon
th a
nd s
hort
er te
rm f
ollo
w u
p.O
dds
rati
os v
arie
d w
idel
y an
d ha
d la
rge
conf
iden
ce in
terv
als.
Non
eof
the
stud
ies
with
12
mon
th f
ollo
w u
p ha
d od
ds r
atio
s si
gnif
ican
tlydi
ffer
ent f
rom
one
. 2
stud
ies
with
6 m
onth
fol
low
up
and
1 st
udy
with
sho
rter
fol
low
up
had
stat
istic
ally
sig
nifi
cant
odd
s ra
tios
grea
ter
than
two.
The
se s
tudi
es in
volv
ed p
sych
osoc
ial i
nter
vent
ions
with
rec
ently
dia
gnos
ed a
lcoh
olic
s w
orki
ng in
an
indu
stri
al s
ettin
g,gr
oup
coup
les
ther
apy
and
com
bina
tion
s of
nal
trex
one
wit
hps
ycho
soci
al th
erap
ies.
Thi
s m
eta-
anal
ysis
pre
date
s m
ost o
f th
est
udie
s on
new
er p
harm
acot
hera
pies
; 7 s
tudi
es in
volv
ed a
vers
ive
ther
apie
s or
lith
ium
trea
tmen
t. T
he w
ide
rang
e of
stu
dyin
terv
entio
ns a
nd s
ettin
gs m
akes
it d
iffi
cult
to d
raw
cle
arco
nclu
sion
s ab
out i
ndiv
idua
l int
erve
ntio
ns.
Ale
xand
er C
N e
t al T
reat
ing
and
prev
enti
ng a
lcoh
ol,
nico
tine
, and
dru
g ab
use
thro
ugh
tran
scen
dent
alm
edita
tion:
a r
evie
w a
ndst
atis
tical
met
a-an
alys
is19
94 A
lcoh
olis
m T
reat
men
t
Yes
Not
rep
orte
d Y
es 19
Var
ious
Of
the
14 s
tudi
es e
xam
inin
g th
e ef
fect
of
TM
on
alco
hol
and
othe
rty
pes
of d
rugs
, 11
stu
dies
fou
nd s
igni
fica
nt d
ecre
ases
in
alco
hol
use/
cons
umpt
ion
or r
educ
tion
in
the
degr
ee o
f th
e al
coho
l pr
oble
m.
The
one
stu
dy e
xam
ined
in d
etai
l fou
nd 6
5% o
f th
e T
M g
roup
wer
eab
stin
ent
com
pare
d to
55%
of
the
EM
G m
uscl
e re
laxa
tion
grou
p,28
%
of
the
neur
othe
rapy
gr
oup,
an
d 25
%
of
thos
e re
ceiv
ing
stan
dard
co
unse
lling
.
For
the
14
stud
ies
repo
rtin
g al
coho
l
108
Qua
rter
ly 1
1(1-
2): 1
3-87
cons
umpt
ion,
the
ave
rage
TM
eff
ect
size
was
0.5
5 (p
=0.
0008
).B
ette
r de
sign
ed T
M s
tudi
es (
i.e.
long
itudi
nal
and
expe
rim
enta
l)pr
oduc
ed a
t le
ast
the
sam
e or
hig
her
aver
age
effe
ct s
izes
tha
nst
udie
s ba
sed
on c
ross
-sec
tiona
l an
d re
tros
pect
ive
surv
ey d
esig
ns.
Ave
rage
eff
ect s
izes
of
TM
wer
e co
mpa
red
to o
ther
trea
tmen
ts.
For
rela
xati
on s
tudi
es t
he a
vera
ge e
ffec
t si
ze f
or 1
1 in
terv
enti
ons
was
0.15
. D
rug
prev
entio
n pr
ogra
mm
es f
or a
dole
scen
ts h
ad a
n ov
eral
lef
fect
siz
e of
0.1
7.
A m
eta-
anal
ysis
of
inte
rven
tions
to
redu
cedr
ivin
g-un
der-
the-
infl
uenc
e (D
UI)
re
cidi
vism
fo
und
an
8-13
%pr
opor
tion
al r
educ
tion
in
DU
I ar
rest
s re
lati
ve t
o co
ntro
ls,
resu
ltin
gin
a s
mal
l bu
t ro
bust
eff
ect
size
of
0.10
, si
gnif
ican
t at
p<
0.01
, tw
o-ta
iled
. B
y co
ntra
st th
e av
erag
e ef
fect
siz
e fo
r T
M w
as 0
.55
(n=
14).
Thi
s re
view
est
abli
shes
tha
t ps
ycho
logi
cal
impr
ovem
ents
pro
duce
dby
TM
gen
eral
ise
to k
now
n su
bsta
nce
abus
ers.
T
M p
rodu
ces
asi
gnif
ican
t ef
fect
on
redu
cing
use
of
alco
hol,
ciga
rette
s, a
nd i
llici
tdr
ugs
in b
oth
the
gene
ral
popu
latio
n (f
urth
er i
ndic
atin
g se
cond
ary
prev
enti
on)
and
in h
eavy
use
rs (
dem
onst
rati
ng t
reat
men
t ef
fica
cy).
The
tim
e co
urse
fo
r T
M
is
dist
inct
ive
with
ab
stin
ence
be
ing
mai
ntai
ned
or i
ncre
ased
ove
r th
e lo
ng t
erm
(in
dica
ting
effe
ctiv
ere
laps
e pr
even
tion
).
The
suc
cess
of
this
nat
ural
tec
hniq
ue t
hus
hold
s im
port
ant
polic
y im
plic
atio
ns
for
both
th
e tr
eatm
ent
and
prev
enti
on o
f su
bsta
nce
abus
e.
Bat
el P
. The
trea
tmen
t of
alco
holi
sm in
Fra
nce.
Dru
gan
d A
lcoh
ol D
epen
denc
e.19
95; 3
9(Su
ppl 1
): 1
5S-
21S.
RC
Ts
publ
ishe
dbe
twee
n19
60 a
nd19
93.
Not
rep
orte
d N
otre
port
ed.
Thi
spa
per
was
not
peer
revi
ewed
19 R
CT
s M
en a
ndW
omen
who
wer
e al
coho
lde
pend
ent o
rpr
oble
mdr
inke
rs.
The
eff
ecti
vene
ss o
f di
ffer
ent p
harm
acot
hera
pies
wer
e co
nsid
ered
inth
e sh
ort-
term
(<
10 w
eeks
), m
ediu
m-t
erm
(11
-16
wee
ks)
and
long
-te
rm
(26-
52
wee
ks).
M
eta-
anal
yses
of
ra
ndom
ised
co
ntro
lled
phar
mac
o-th
erap
eutic
stu
dies
of
patie
nts
trea
ted
for
alco
hol-
rela
ted
diso
rder
s in
dica
ted
that
ce
rtai
n dr
ugs,
su
ch
as
cita
lopr
am,
fluo
xeti
ne,
nalt
rexo
ne,
and
acam
pros
ate,
app
ear
to b
e be
nefi
cial
in
the
trea
tmen
t of
alc
ohol
ism
, w
hile
zim
eldi
ne,
tetr
abat
ate,
L-d
opa,
and
vilo
xazi
ne
are
not.
T
he
resu
lts
for
lithi
um,
phen
ytoi
n,br
omoc
ript
ine,
ap
omor
phin
e,
and
busp
iron
e w
ere
mix
ed.
T
heid
entif
icat
ion
of a
lcoh
olic
pat
ient
s w
ho w
ill r
espo
nd t
o sp
ecif
icdr
ugs
will
rep
rese
nt s
igni
fica
nt p
rogr
ess
in th
is f
ield
. B
rew
er C
et a
l. D
oes
Dis
ulfi
ram
hel
p to
pre
vent
rela
pse
in a
lcoh
ol a
buse
?
Not
repo
rted
Stud
ies
incl
uded
wer
e cl
inic
alst
udie
s w
ith
Not
repo
rted
18 s
tudi
esw
ere
incl
uded
. 13
Alc
ohol
depe
nden
t A
lthou
gh i
t is
not
sug
gest
ed t
hat
supe
rvis
ed D
isul
fira
m,
is n
eede
dfo
r al
l pa
tient
s,
ther
e ar
e se
vera
l si
tuat
ions
in
w
hich
it
seem
spa
rtic
ular
ly
help
ful.
Fo
r ex
ampl
e,
patie
nts
with
a
hist
ory
of
109
CN
S D
rugs
. 200
0; 1
4(5)
:32
9-41
.ev
iden
ce th
atat
tem
pts
had
been
mad
e to
ensu
re th
atdi
sulf
iram
adm
inis
trat
ion
was
dir
ectly
supe
rvis
ed a
tle
ast o
nce
aw
eek.
wer
eco
ntro
lled
, 5w
ere
not
cont
rolle
d.
repe
ated
tre
atm
ent
failu
re,
or p
atie
nts
who
hav
e m
any
drin
king
trig
gers
an
d th
ose
faci
ng
seri
ous
cons
eque
nces
if
th
ey
rela
pse.
Pro
vide
d th
at a
ttent
ion
is p
aid
to t
he d
etai
ls o
f su
perv
isio
n an
d th
atsu
perv
isor
s ar
e gi
ven
appr
opri
ate
trai
ning
, su
perv
ised
Dis
ulfi
ram
is
a si
mpl
e an
d ef
fect
ive
addi
tion
to
psyc
hoso
cial
tr
eatm
ent
prog
ram
mes
.
Com
pare
d w
ith
unsu
perv
ised
D
isul
fira
m
or
noD
isul
fira
m c
ontr
ol g
roup
s, i
t re
duce
s dr
inki
ng, p
rolo
ngs
rem
issi
ons,
impr
oves
tr
eatm
ent
rete
ntio
n an
d fa
cilit
ates
co
mpl
ianc
e w
ithps
ycho
soci
al
inte
rven
tion
s su
ch
as
com
mun
ity
rein
forc
emen
t,m
arita
l an
d ne
twor
k th
erap
ies.
Su
perv
ised
dis
ulfi
ram
app
ears
to
bem
ore
effe
ctiv
e th
an
supe
rvis
ed
Nal
trex
one
and
may
be
m
ore
effe
ctiv
e th
an
unsu
perv
ised
A
cam
pros
ate.
The
im
port
ance
of
supe
rvis
ing
the
cons
umpt
ion
of d
isul
fira
m h
as b
een
over
look
ed o
rm
inim
ised
by
man
y re
view
ers.
C
arr
A. E
vide
nce-
base
dpr
actic
e in
fam
ily th
erap
yan
d sy
stem
atic
con
sulta
tion
II A
dult-
focu
sed
prob
lem
s.Jo
urna
l of
Fam
ily T
hera
py.
2000
; 22:
273
-95.
Not
repo
rted
Exc
lude
d: S
ingl
eca
se r
epor
ts a
ndsi
ngle
gro
upou
tcom
e st
udie
s
Not
repo
rted
Not
rep
orte
d Fa
mili
es a
ndco
uple
s D
escr
ibes
met
a-an
alys
is b
y E
dwar
ds &
Ste
ingl
ass,
199
5, in
clud
edin
this
sec
tion.
Cas
sidy
CL
. Occ
upat
iona
lth
erap
y in
terv
entio
n in
the
trea
tmen
t of
alco
holi
cs.
Occ
upat
iona
l The
rapy
inM
enta
l Hea
lth. 1
988;
8(2
):17
-26.
Not
repo
rted
Not
rep
orte
d N
otre
port
ed N
ot r
epor
ted
Men
,w
omen
,yo
ung
and
elde
rly
peop
le li
ving
in u
rban
area
s an
dw
ho w
ere
alco
hol
depe
nden
t.
It is
est
imat
ed th
at e
ach
alco
holi
c ne
gati
vely
eff
ects
an
aver
age
of 4
othe
r pe
rson
s su
ffic
ient
ly f
or th
ese
othe
r vi
ctim
s to
req
uire
coun
selli
ng a
nd/o
r su
ppor
t to
reco
ver.
Cur
rent
use
of
occu
patio
nal
ther
apy
in t
his
area
of
trea
tmen
t pra
ctic
e is
min
imal
. A
pos
itive
resp
onse
to ta
sk a
nd a
ctiv
ity o
rien
ted
occu
patio
nal t
hera
py g
roup
sha
s be
en in
dica
ted.
The
val
ue o
f oc
cupa
tion
al th
erap
y in
terv
enti
onw
ith a
lcoh
olic
s st
ill n
eeds
to b
e pr
oven
.
Chi
ck J
. Aca
mpr
osat
e as
an
aid
in th
e tr
eatm
ent o
fal
coho
lism
. Alc
ohol
&A
lcoh
olis
m 1
995;
30(
6):
785-
7.
Not
repo
rted
. R
ando
mis
ed-
cont
rolle
dst
udie
s
Not
repo
rted
4 st
udie
s, 3
of w
hich
are
incl
uded
inth
e D
TB
revi
ew.
Not
repo
rted
. L
oss
to f
ollo
w-u
p is
a m
ajor
pro
blem
whe
n in
terp
retin
g re
sults
of
trea
tmen
t out
com
e in
alc
ohol
-dep
ende
nt s
ampl
es w
hen
stud
ies
exte
nd o
ver
man
y m
onth
s. F
or th
e se
tting
s re
port
ed o
n to
dat
e,A
cam
pros
ate
is a
hel
pful
adj
unct
to c
onve
ntio
nal o
ut-p
atie
nttr
eatm
ent a
fter
det
oxif
icat
ion.
Not
all
patie
nts
resp
ond,
and
the
char
acte
rist
ics
of r
espo
nden
ts h
ave
yet t
o be
def
ined
. T
he a
mou
nt
110
and
type
of
prec
edin
g an
d co
llat
eral
psy
chos
ocia
l and
/or
phar
mac
olog
ical
trea
tmen
t whi
ch b
est f
acili
tate
s re
spon
se to
Aca
mpr
osat
e ha
s al
so y
et to
be
spec
ifie
d. D
eRub
eis
RJ,
Cri
ts-
Chr
isto
ph P
. Em
piri
cally
supp
orte
d in
divi
dual
and
grou
p ps
ycho
logi
cal
trea
tmen
ts f
or a
dult
men
tal
diso
rder
s. J
ourn
al o
fC
onsu
lting
and
Clin
ical
Psy
chol
ogy.
199
8; 6
6(1)
:37
-52.
Not
repo
rted
Exc
lude
d st
udie
sha
d an
abs
ence
of a
dif
fere
nce
betw
een
trea
tmen
ts o
rbe
twee
n a
trea
tmen
t and
aco
ntro
l gro
up in
the
sam
e st
udy.
Stud
ies
with
an
impr
ecis
ede
scri
ptio
n of
the
popu
latio
n or
trea
tmen
t und
erin
vest
igat
ion.
Not
repo
rted
3 st
udie
sw
ere
desc
ribe
d in
the
revi
ewan
d 3
3di
ffer
ent
trea
tmen
tm
odal
ities
conc
erni
ngal
coho
l wer
ein
clud
ed in
the
revi
ew.
Alc
ohol
depe
nden
tdr
inke
rs a
ndhe
avy
drin
kers
.
Soci
al s
kills
trai
ning
del
iver
ed in
a g
roup
for
mat
pro
duce
d be
tter
outc
omes
than
trad
ition
al d
iscu
ssio
n gr
oup.
Ove
r th
e 1-
year
per
iod
afte
r di
scha
rge,
pat
ient
s w
ho h
ad r
ecei
ved
soci
al s
kills
trai
ning
wer
eab
stin
ent 7
7% o
f da
ys, w
here
as c
ontr
ol p
atie
nts
wer
e ab
stin
ent 3
2%of
day
s. T
ime
until
rel
ativ
ely
heav
y dr
inki
ng a
mon
g th
e cu
eex
posu
re p
artic
ipan
ts a
vera
ged
110
days
, as
oppo
sed
to 6
4 da
ys f
orpa
rtic
ipan
ts in
the
rela
xatio
n co
nditi
on.
Ade
quat
e ev
iden
ce e
xist
sfo
r de
sign
atin
g cu
e ex
posu
re th
erap
y, c
ue e
xpos
ure
ther
apy
plus
copi
ng s
kills
trai
ning
, and
soc
ial s
kills
trai
ning
as
poss
ibly
effi
caci
ous
trea
tmen
ts f
or a
lcoh
ol d
epen
denc
e. I
t is
beli
eved
that
the
know
ledg
e th
at a
trea
tmen
t has
bee
n sh
own
to b
e ef
fica
ciou
s sh
ould
affe
ct d
ecis
ions
abo
ut h
ow o
ne tr
ains
ther
apis
ts a
s w
ell a
s ho
w o
nepr
acti
ces
psyc
holo
gica
l the
rapy
Din
h-Z
arr
T, D
iGui
sepp
i C,
Hei
tman
E, R
ober
ts I
.P
reve
ntin
g in
juri
es th
roug
hin
terv
entio
ns f
or p
robl
emdr
inki
ng: A
sys
tem
atic
revi
ew o
f ra
ndom
ised
cont
rolle
d tr
ials
. A
lcoh
ol &
Alc
ohol
ism
199
9; 3
4(4)
:60
9-21
.
Yes
Stud
ies
incl
uded
had
subj
ects
rand
omly
assi
gned
toex
peri
men
tal a
ndco
ntro
l gro
ups;
and
inte
rven
tions
desi
gned
tore
duce
or
elim
inat
e al
coho
lco
nsum
ptio
n, o
rto
pre
vent
inju
ries
or
thei
ran
tece
dent
s; a
ndif
out
com
em
easu
res
incl
uded
inju
ries
or th
eir
ante
cede
nts.
Yes
19 tr
ials
met
the
incl
usio
ncr
iteri
a
Alc
ohol
depe
nden
ce,
alco
hol
abus
e, o
rot
her
prob
lem
drin
king
.
Thi
s sy
stem
atic
rev
iew
con
side
rs th
e ef
fect
of
a ra
nge
ofin
terv
entio
ns o
n in
juri
es a
nd d
eath
s. T
he r
esul
ts s
ugge
st th
attr
eatm
ent f
or p
robl
em d
rink
ing
may
red
uce
inju
ries
and
thei
ran
tece
dent
s, b
ut th
ere
wer
e a
num
ber
of m
etho
dolo
gica
l wea
knes
ses
and
effe
ct s
izes
wer
e of
ten
impr
ecis
e. B
ecau
se in
juri
es a
ccou
nt f
orm
uch
of th
e m
orbi
dity
and
mor
talit
y fr
om p
robl
em d
rink
ing,
fur
ther
stud
ies
are
war
rant
ed to
con
firm
thes
e ef
fect
s. T
he r
evie
w d
id n
otpr
ovid
e st
rong
sup
port
for
red
uced
alc
ohol
con
sum
ptio
n as
the
mec
hani
sm f
or in
jury
red
ucti
on.
(Thi
s re
view
is a
lso
avai
labl
e in
the
Coc
hran
e L
ibra
ry).
111
Don
aghy
ME
and
Mut
rie
NIs
exe
rcis
e be
nefi
cial
in th
etr
eatm
ent a
nd r
ehab
ilita
tion
of th
e pr
oble
m d
rink
er?
Acr
itica
l rev
iew
. 199
9P
hysi
cal T
hera
py R
evie
ws
4; 1
53-1
66
Yes
Stud
ies
had
toin
clud
e a
clin
ical
lyde
fine
dpo
pula
tion
ofpr
oble
mdr
inke
rs.
Not
repo
rted
3 B
ritis
hst
udie
s an
d 6
inte
rnat
iona
l.
Prob
lem
drin
kers
Phys
ical
exe
rcis
e re
gim
ens
have
a p
osit
ive
effe
ct o
n ae
robi
c fi
tnes
san
d st
reng
th if
adm
inis
tere
d as
an
adju
nct t
o tr
eatm
ent a
ndre
habi
litat
ion
of p
robl
em d
rink
ers.
Onl
y 3
stud
ies
cons
ider
eddr
inki
ng b
ehav
iour
as
an o
utco
me.
Tw
o of
the
stud
ies
used
sel
fre
port
ed b
ehav
iour
; one
fou
nd n
o ef
fect
and
one
rep
orte
d su
stai
ned
abst
inen
ce.
One
stu
dy u
sed
CD
T a
s a
mar
ker
of a
bsti
nenc
e an
dfo
und
no e
ffec
t at 2
or
5 m
onth
s. E
dwar
ds M
E, S
tein
glas
s P
.Fa
mily
ther
apy
trea
tmen
tou
tcom
es f
or a
lcoh
olis
m.
Jour
nal o
f M
arita
l and
Fam
ily T
hera
py. 1
995;
21(4
): 4
75-5
09.
Not
repo
rted
Incl
uded
: the
stud
y ev
alua
ted
the
effe
ctiv
enes
sof
a f
amily
-in
volv
edtr
eatm
ent f
oral
coho
lism
; use
dat
leas
t a q
uasi
-ex
peri
men
tal
desi
gn,
com
pari
ng a
trea
tmen
t gro
upw
ith
a co
ntro
lgr
oup;
rep
orte
dob
ject
ive
outc
ome
data
abou
t sub
ject
’sal
coho
lco
nsum
ptio
nan
d/or
dri
nkin
gre
late
d pr
oble
ms
afte
r tr
eatm
ent
and
had
wel
lde
fine
d cr
iteri
aof
suc
cess
.
Yes
21 s
tudi
es o
ffa
mily
-in
volv
edth
erap
y. 4
are
conc
erne
dw
ith th
ein
itiat
ion
oftr
eatm
ent,
15w
ith p
rim
ary
trea
tmen
t /re
habi
litat
ion,
and
2 w
ithaf
terc
are.
Fam
ilies
The
stu
dies
of
the
initi
atio
n of
tre
atm
ent
stag
e de
mon
stra
ted
the
pow
erfu
l ef
fect
tha
t fa
mily
mem
bers
hav
e no
t on
ly i
n m
otiv
atin
gal
coho
lics
to g
et t
reat
men
t bu
t al
so i
n al
teri
ng d
rink
ing
beha
viou
r.T
his
is c
onfi
rmed
by
the
stat
isti
call
y si
gnif
ican
t av
erag
e ef
fect
siz
efo
r en
teri
ng tr
eatm
ent o
f 1.
83.
The
pri
mar
y tr
eatm
ent/r
ehab
ilita
tion
phas
e fo
und
the
over
all
the
mea
n ef
fect
siz
e to
be
a si
gnif
ican
t 0.
86,
and
the
stud
ies
eval
uati
ngth
e af
terc
are
phas
e fo
und
a si
gnif
ican
t av
erag
e ef
fect
siz
e of
0.9
4,fo
r th
e ou
tcom
e m
easu
re
of
abst
inen
ce.
T
he
data
ab
out
the
effe
ctiv
enes
s of
af
terc
are
prog
ram
s is
at
th
is
poin
t th
e le
ast
sati
sfac
tory
. T
he e
vide
nce
from
bot
h th
e ef
fect
siz
e an
d th
e cl
inic
alsi
gnif
ican
ce d
ata
sugg
ests
tha
t bo
th s
impl
e an
d el
abor
ate
fam
ily-
invo
lved
int
erve
ntio
ns h
elp
to m
aint
ain
trea
tmen
t ga
ins
in t
he s
hort
run.
Thi
s re
view
su
gges
ts
2 m
ajor
co
nclu
sion
s (1
) fa
mily
th
erap
yap
proa
ches
ar
e ef
fect
ive
trea
tmen
ts
for
alco
holi
sm;
but
(2)
its
impa
ct is
dif
fere
ntia
lly f
elt d
epen
ding
on
at le
ast 3
add
ition
al f
acto
rs–
gend
er
of
the
alco
holic
, in
vest
men
t in
th
e re
latio
nshi
p,
and
supp
ort f
or a
bstin
ence
fro
m th
e fa
mily
.
Fulle
r R
K, H
iller
-St
urm
hofe
l S. A
lcoh
olis
mtr
eatm
ent i
n th
e U
nite
dSt
ates
: an
over
view
. Alc
ohol
Res
earc
h &
Hea
lth. 1
999;
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
Not
rep
orte
d N
otre
port
ed.
Des
crib
es f
orm
s of
rel
apse
pre
vent
ion
as p
art o
f a
wid
er r
evie
w o
fal
coho
l tre
atm
ent i
n th
e U
S. C
ompa
riso
n of
the
mai
n fo
rms
ofps
ycho
soci
al in
terv
entio
n, r
epor
ted
from
Pro
ject
MA
TC
H, s
how
little
dif
fere
nce
in e
ffec
tiven
ess.
12
Step
Fac
ilita
tion
(TSF
) ha
dso
me
adva
ntag
es w
ith
pati
ents
who
had
rec
eive
d ea
rlie
r in
pati
ent
112
23(2
): 6
9-77
.ca
re.
Mot
ivat
iona
l enh
ance
men
t the
rapy
(M
ET
) ha
d po
orer
outc
omes
at 3
mon
ths
(28%
of
patie
nts
cont
inuo
usly
abs
tinen
t or
drin
king
mod
erat
ely
com
pare
d w
ith 4
1% f
or T
SF a
nd c
ogni
tive
beha
viou
ral t
hera
py (
CB
T))
. H
owev
er, o
utco
mes
ove
r th
e 3
year
foll
ow u
p w
ere
com
para
ble.
Proj
ect M
AT
CH
aim
ed to
ass
ess
the
adde
d ef
fect
of
mat
chin
gpa
tient
s to
trea
tmen
ts b
ut f
ound
onl
y lim
ited
supp
ort f
or th
isap
proa
ch.
TSF
wor
ked
bette
r th
an C
BT
for
mor
e de
pend
ent
patie
nts
who
had
pre
viou
sly
been
inpa
tient
s. M
ET
was
the
mos
tef
fect
ive
trea
tmen
t with
out
patie
nts
with
hig
h le
vels
of
ange
r. T
SFw
as p
artic
ular
ly e
ffec
tive
with
out
patie
nts
who
se s
ocia
l net
wor
kssu
ppor
ted
drin
king
. A
bri
ef r
evie
w o
f ph
arm
acot
hera
pies
is r
epor
ted.
Gal
aif
ER
, Sus
sman
S. F
orw
hom
doe
s A
lcoh
olic
sA
nony
mou
s w
ork?
. The
Inte
rnat
iona
l Jou
rnal
of
the
Add
ictio
ns. 1
995;
30(
2):
161-
84.
Not
repo
rted
Not
rep
orte
d N
otre
port
ed 7
stud
ies,
4w
hich
are
cros
s-se
ctio
nal a
nd3
are
long
itudi
nal
stud
ies.
Men
,W
omen
, and
elde
rly
peop
le o
fva
riou
sso
cial
cla
ssan
d et
hnic
grou
ps.
Pro
blem
drin
kers
,he
avy
drin
kers
and
alco
hol
depe
nden
tdr
inke
rs.
The
re i
s ev
iden
ce t
hat
som
e fo
rm o
f lo
ng-t
erm
tre
atm
ent,
form
al o
rin
form
al,
is
nece
ssar
y to
ef
fect
ivel
y tr
eat
alco
holi
sm.
St
able
mem
bers
of
A.A
. ten
d to
be
mid
dle
clas
s, m
ale,
sin
gle
or e
stra
nged
from
on
e’s
fam
ily,
havi
ng
fam
ilial
pr
oble
ms,
re
ceiv
ing
less
educ
atio
n, a
nd b
eing
old
er th
an n
on-m
embe
rs o
f th
ose
who
dro
p ou
tof
A.A
. A
.A m
ay b
e re
lativ
ely
unlik
ely
to h
elp
thos
e w
ho a
re:
unco
mfo
rtab
le
in
larg
e cr
owds
or
in
tim
ate
mee
ting
s,
are
not
relig
ious
ly
orie
nted
an
d ar
e no
t sa
tisfi
ed
with
th
e re
ligio
usov
erto
nes,
are
mem
bers
of
min
orit
y cl
asse
s (w
omen
, eth
nici
ty o
ther
than
Cau
casi
an,
and
low
er s
ocio
-eco
nom
ic s
tatu
s),
do n
ot f
it t
heA
.A.’
s de
fini
tion
of a
lcoh
olis
m o
r w
ho h
ave
a de
sire
of
cont
rolle
ddr
inki
ng a
s a
goal
, ar
e du
al-d
iagn
osed
, w
ith
both
alc
ohol
ism
and
anot
her
seri
ous
diso
rder
, an
d ar
e in
nee
d of
psy
chol
ogic
ally
-bas
edtr
eatm
ent.
Gar
butt
JC
, Wes
t SL
, Car
eyT
S, L
ohr
KN
, Cre
ws
FT.
Pha
rmac
olog
ical
trea
tmen
tof
alc
ohol
dep
ende
nce:
Are
view
of
the
evid
ence
.JA
MA
199
9; 2
81(1
4):
1318
-25.
Yes
Incl
uded
RC
Ts
and
othe
r ro
bust
desi
gns
with
sam
ples
gre
ater
than
10.
Stu
dies
loca
ted
in th
eU
S, C
anad
a,E
urop
e, L
atin
Am
eric
a, A
sia,
Yes
41 s
tudi
esan
d 11
follo
w u
p or
subg
roup
stud
ies.
4 o
f9
stud
ies
onac
ampr
osat
ear
e in
clud
edin
DT
B
Non
preg
nant
,al
coho
lde
pend
ent
adul
ts.
Dis
ulfi
ram
. 11
tria
ls w
ere
revi
ewed
. O
utco
me
mea
sure
s an
d re
sult
sva
ried
.
The
re
is
mod
est
evid
ence
of
re
duct
ion
in
drin
king
freq
uenc
ies
but n
o ev
iden
ce o
f im
prov
ed a
bsti
nenc
e ra
tes.
Opi
ate
anta
goni
sts.
4
tria
ls w
ere
revi
ewed
. S
ampl
e si
zes
wer
em
odes
t bu
t tr
ials
wer
e go
od q
uali
ty.
One
stu
dy p
rovi
ded
evid
ence
on th
e in
tera
ctio
n w
ith p
sych
othe
rapy
. A
cam
pros
ate.
9 tr
ials
w
ere
revi
ewed
.
The
m
ost
cons
iste
ntev
iden
ce o
f ef
fect
iven
ess
is f
or d
rink
ing
freq
uenc
y; n
on-d
rink
ing
days
inc
reas
ed b
y 30
% t
o 50
%.
Som
e tr
ials
als
o re
port
a p
ositi
ve
113
Aus
tral
ia/N
ewZ
eala
nd;
publ
ishe
d in
Eng
lish,
Fre
nch
or G
erm
an.
Inpa
tien
t and
outp
atie
nts
setti
ngs
wer
ein
clud
ed.
revi
ewef
fect
on
abst
inen
ce r
ates
(43
% v
ersu
s 30
% f
or c
ontr
ols
at 6
mon
ths
in o
ne s
tudy
; 40%
ver
sus
17%
at 4
8 w
eeks
in a
noth
er).
Sero
tone
rgic
age
nts
and
lithi
um.
The
se m
edic
atio
ns m
ay h
ave
apo
sitiv
e ef
fect
in p
atie
nts
with
coe
xist
ing
psyc
hiat
ric
diso
rder
s.
For
pati
ents
wit
h pr
imar
y al
coho
l de
pend
ence
the
ir u
se d
oes
not
appe
arto
be
supp
orte
d by
the
data
ava
ilabl
e. It
is
note
d th
at t
he t
reat
men
t of
pat
ient
s w
ith a
lcoh
olis
m s
houl
dco
ntin
ue t
o in
corp
orat
e a
psyc
hoso
cial
per
spec
tive
in
an e
ffor
t to
chan
ge a
life
fro
m a
pat
tern
of
addi
ctio
n to
a p
atte
rn o
f so
brie
ty a
ndim
prov
ed p
hysi
cal,
men
tal,
and
soci
al h
ealt
h.
Hoe
s M
JA. R
elap
sepr
even
tion
in a
lcoh
olic
s: A
revi
ew o
f A
cam
pros
ate
vers
us N
altr
exon
e. C
linic
alD
rug
Inve
stig
atio
n. 1
999;
17(3
): 2
11-6
.
Not
repo
rted
Incl
uded
stu
dies
are
publ
ishe
d,do
uble
-blin
d,pl
aceb
o-co
ntro
lled
tria
lsof
pat
ient
sab
usin
g or
depe
nden
t on
alco
hol.
Not
repo
rted
11 s
tudi
esco
ncer
ning
Aca
mpr
osat
ean
d 4
stud
ies
conc
erni
ngN
altr
exon
e.
Alc
ohol
depe
nden
t B
oth
drug
s w
ere
effe
ctiv
e, b
ut A
cam
pros
ate
may
be
pref
erre
d ov
erN
altr
exon
e du
e to
its
pro
ven
long
-ter
m e
ffec
tiven
ess
with
car
ry-
over
. A
cam
pros
ate
incr
ease
s th
e nu
mbe
r of
day
s th
at n
o al
coho
l is
cons
umed
for
ove
r 1
year
aft
er 1
yea
r m
aint
enan
ce t
reat
men
t, w
hile
6 m
onth
s af
ter
Nal
trex
one
has
been
sto
pped
no
ther
apeu
tic r
esid
ual
effe
ct h
as b
een
noti
ced.
A
cam
pros
ate
has
been
sho
wn
to i
ncre
ase
mea
n co
ntin
uous
alc
ohol
abs
tine
nce
rate
s, c
umul
ativ
e du
rati
on o
fab
stin
ence
and
tim
e to
fir
st a
lcoh
olic
dri
nk c
ompa
red
wit
h pl
aceb
o,w
hile
N
altr
exon
e re
duce
d th
e ra
te
of
alco
hol
drin
king
re
laps
e,nu
mbe
rs o
f dr
inki
ng d
ays
and
alco
hol
crav
ing.
N
altr
exon
e ca
used
mor
e ad
vers
e ef
fect
s th
an A
cam
pros
ate.
Hug
hes
JC, C
ook
CC
H. T
heef
fica
cy o
f D
isul
fira
m: A
revi
ew o
f ou
tcom
e st
udie
s.A
ddic
tion
1997
; 92(
4): 3
81-
95.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
. 38
stu
dies
;24
ora
ldi
sulf
iram
and
14im
plan
ted.
Not
repo
rted
. E
vide
nce
in f
avou
r of
the
use
of im
plan
ted
Dis
ulfi
ram
is p
artic
ular
lyla
ckin
g an
d th
ere
is
no
just
ific
atio
n fo
r th
e us
e of
im
plan
ted
Dis
ulfi
ram
tab
lets
. S
tudi
es o
f or
al D
isul
fira
m h
ave
prov
ed t
o be
inhe
rent
ly m
etho
dolo
gica
lly d
iffi
cult,
so
that
few
stu
dies
giv
e a
clea
r st
atem
ent
on e
ffic
acy.
O
ral
Dis
ulfi
ram
see
ms
to h
ave
som
eef
fica
cy i
n re
duci
ng t
he n
umbe
r of
dri
nkin
g da
ys a
nd t
he a
mou
nts
drun
k in
pat
ient
s w
ho a
re c
ompl
iant
with
tre
atm
ent
regi
mes
, eve
n if
they
co
ntin
ue
to
drin
k.
Fu
ture
re
sear
ch
mig
ht
conc
entr
ate
onde
liver
ing
Dis
ulfi
ram
, or
its a
ctiv
e m
etab
olite
s, e
ffec
tivel
y by
dep
otin
ject
ion;
or
rese
arch
mig
ht f
urth
er a
ttem
pt b
oth
to t
est
hypo
thes
esco
ncer
ning
pa
tient
-tre
atm
ent
mat
chin
g an
d to
id
entif
y pa
tient
char
acte
rist
ics
pred
ictiv
e of
goo
d ou
tcom
e w
ith o
ral D
isul
fira
m.
Ir
vin
JE, B
ower
s C
A, D
unn
ME
, Wan
g M
C. E
ffic
acy
of N
otre
port
ed.
Stud
ies
incl
uded
iden
tifie
d th
e
22 p
ublis
hed
and
4 N
otre
port
ed.
Thi
s re
view
was
con
cern
ed w
ith c
ogni
tive-
beha
viou
ral t
hera
py(C
BT
) as
an
appr
oach
to r
elap
se p
reve
ntio
n in
sub
stan
ce m
isus
ege
nera
lly.
It
was
sho
wn
as m
ost e
ffec
tive
whe
n ap
plie
d to
alc
ohol
114
rela
pse
prev
entio
n: A
met
a-an
alyt
ic r
evie
w. J
ourn
al o
fC
onsu
lting
& C
linic
alP
sych
olog
y 19
99; 6
7 (4
):56
3-70
.
trea
tmen
tap
proa
ch a
sre
laps
epr
even
tion
,re
port
ed te
stst
atis
tics
asso
ciat
ed w
ith
outc
omes
, and
com
pare
dtr
eatm
ent w
ithno
-add
ition
al-
trea
tmen
tco
ntro
ls, o
ther
activ
ein
terv
entio
ns,
disc
ussi
onco
ntro
ls,
phys
icia
nad
vice
, or
unco
ntro
lled
pre-
post
test
s.
unpu
blis
hed
stud
ies
mis
use.
The
ave
rage
eff
ect s
ize
for
alco
hol s
tudi
es w
ere
sim
ilar
rega
rdle
ss o
f in
divi
dual
or
grou
p fo
rmat
for
del
iver
y. A
djun
ctiv
eus
e of
med
icat
ion
may
sub
stan
tial
ly in
crea
se e
ffec
tive
ness
for
alco
hol p
robl
ems.
Gen
eral
ly, s
tudi
es th
at u
sed
unve
rifi
ed s
elf-
repo
rt h
ad s
igni
fica
ntly
larg
er e
ffec
t siz
es.
Kow
nack
i RJ,
Sha
dish
WR
.D
oes
Alc
ohol
ics
Ano
nym
ous
wor
k?: T
here
sults
fro
m a
met
a-an
alys
isof
con
trol
led
expe
rim
ents
.Su
bsta
nce
Use
& M
isus
e.19
99; 3
4(13
): 1
897-
1916
.
Not
repo
rted
Stud
ies
incl
uded
are
cont
roll
edtr
ials
, (ex
clud
ing
corr
elat
iona
lst
udie
s an
d on
egr
oup
desi
gns)
.
Not
repo
rted
21 s
tudi
esin
volv
ing
appr
oxim
atel
y 7,
000
subj
ects
.
Men
and
wom
en f
rom
vari
ous
ethn
icgr
oups
and
soci
al c
lass
who
are
alco
hol
depe
nden
t.
Ran
dom
ised
st
udie
s yi
elde
d w
orse
re
sults
fo
r A
A
than
no
n-ra
ndom
ised
st
udie
s,
but
wer
e bi
ased
by
se
lect
ion
of
coer
ced
subj
ects
. A
ttend
ing
conv
entio
nal
AA
mee
tings
was
wor
se t
han
non
trea
tmen
t or
al
tern
ativ
e tr
eatm
ent,
resi
dent
ial
AA
-mod
elle
dtr
eatm
ents
pe
rfor
med
no
be
tter
or
wor
se
than
al
tern
ativ
es,
and
seve
ral c
ompo
nent
s of
AA
see
med
sup
port
ed (
reco
veri
ng a
lcoh
olic
sas
th
erap
ists
, pe
er-l
ed
self
-hel
p th
erap
y gr
oups
, te
achi
ng
the
Tw
elve
-Ste
p pr
oces
s, a
nd d
oing
an
hone
st i
nven
tory
).
The
res
ults
sugg
est
that
is
prob
ably
a b
ad i
dea
to c
oerc
e in
divi
dual
s to
atte
ndco
nven
tion
al A
A m
eeti
ngs,
for
exa
mpl
e, t
he w
ides
prea
d pr
acti
ce o
fco
urt-
orde
red
atte
ndan
ce A
A m
eeti
ngs.
C
oerc
ion
appa
rent
ly y
ield
ssi
gnif
ican
tly w
orse
res
ults
tha
n tr
eatm
ent
alte
rnat
ives
, an
d no
n-si
gnif
ican
tly w
orse
tha
n do
ing
noth
ing
at a
ll.
Bet
ter
to r
efer
the
sepa
tient
s to
so
me
alte
rnat
ives
lik
e ps
ycho
ther
apy
or
inpa
tient
trea
tmen
t.
115
Lej
oyeu
x M
, Ade
s J.
Eva
luat
ion
of li
thiu
mtr
eatm
ent i
n al
coho
lism
.A
lcoh
ol &
Alc
ohol
ism
1993
; 28(
3): 2
73-9
.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
. 3 un
cont
rolle
dst
udie
s an
d 5
cont
rolle
dst
udie
s
Men
und
er35
yea
rs,
Men
ove
r 35
year
s,W
omen
.
Mos
t of
the
rec
ent
stud
ies
fail
ed t
o de
mon
stra
te a
sig
nifi
cant
eff
ect
of li
thiu
m o
n th
e de
pres
sive
sym
ptom
s of
alc
ohol
ics.
Dro
p ou
t rat
esfr
om th
e 5
cont
rolle
d st
udie
s w
ere
betw
een
28%
and
59%
. L
ithiu
mw
as n
ot s
how
n to
be
an e
ffec
tive
tre
atm
ent
of a
ffec
tive
dis
orde
rs i
nal
coho
lics.
T
he l
ates
t pu
blis
hed
stud
ies
also
sug
gest
tha
t lit
hium
trea
tmen
t do
es n
ot d
ecre
ase
alco
hol
inta
ke o
r cr
avin
g fo
r al
coho
l in
eith
er d
epre
ssed
or
non-
depr
esse
d al
coho
lics.
L
ejoy
eux
M. U
se o
fse
roto
nin
(5-
hydr
oxyt
rypt
amin
e)re
upta
ke in
hibi
tors
in th
etr
eatm
ent o
f al
coho
lism
.A
lcoh
ol &
Alc
ohol
ism
1996
: 31(
Supp
l.1):
69-
75.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
7 st
udie
sco
veri
ng 3
diff
eren
tfo
rmul
atio
ns
Incl
uded
mild
tom
oder
ate
drin
kers
as
wel
l as
heav
ydr
inke
rs a
ndal
coho
lde
pend
ent.
Mos
t tri
als
wer
e sm
all a
nd h
ad s
hort
fol
low
up.
Eff
ects
on
alco
hol
inta
ke w
ere
tran
sien
t and
mos
tly in
pat
ient
s w
ith lo
wer
leve
ls o
fal
coho
l int
ake.
Pat
ient
s w
ho r
epor
t a s
igni
fica
nt d
eclin
e in
cra
ving
for
alco
hol m
ay o
nly
slig
htly
dec
reas
e th
eir
alco
hol i
ntak
e. N
osu
bjec
t tra
it p
redi
cted
ther
apeu
tic
resp
onse
, the
refo
re, t
hera
peut
icef
fect
s ca
nnot
be
max
imis
ed b
y gr
oupi
ng p
atie
nts
acco
rdin
g to
thes
epo
ssib
le p
redi
ctor
s of
out
com
e. T
here
is c
lear
ly a
nee
d fo
r lo
ng-
term
stu
dies
that
incl
ude
sim
ulta
neou
s ev
alua
tion
of a
nxie
ty,
depr
essi
on a
nd a
lcoh
ol in
take
.
Mal
ec T
S et
al.
Eff
icac
y of
Bus
piro
ne in
alc
ohol
depe
nden
ce: A
rev
iew
.A
lcoh
olis
m: C
linic
al a
ndE
xper
imen
tal R
esea
rch.
1996
; 20(
5):8
53-8
.
Not
repo
rted
Stud
ies
wer
eex
clud
ed if
the
subj
ects
had
ahi
stor
y of
dru
gad
dict
ion,
oth
erps
ycho
trop
hic
agen
tsad
min
iste
red
inre
cent
wee
ks, o
rus
e of
Dis
ulfi
ram
and
Ben
zodi
azep
ines
.
Not
repo
rted
. 5
publ
ishe
d,co
ntro
lled
stud
ies
onth
e ef
fect
s of
Bus
piro
ne in
alco
hol
trea
tmen
t.
Men
and
wom
en w
how
ere
diag
nose
dw
ith
alco
hol
abus
e or
alco
hol
depe
nden
ce.
The
mai
n ef
fect
of
Bus
piro
ne in
the
trea
tmen
t of
alco
holi
sm is
not
on e
than
ol c
onsu
mpt
ion
per
se, b
ut o
n as
soci
ated
psyc
hopa
thol
ogic
al s
ympt
oms.
A f
avou
rabl
e sa
fety
pro
file
and
ala
ck o
f in
tera
ctio
n w
ith a
lcoh
ol m
ake
Bus
piro
ne a
use
ful
phar
mac
olog
ical
adj
unct
in th
e tr
eatm
ent o
f al
coho
lism
. It
ispo
ssib
le th
at, i
n a
targ
eted
trea
tmen
t str
ateg
y, B
uspi
rone
may
be
aus
eful
adj
unct
in a
lcoh
olic
s w
ith h
igh
coex
iste
nt p
sych
opat
holo
gy,
eith
er a
nxie
ty o
r ot
her
dual
dia
gnos
es.
It s
eem
s su
peri
or in
thes
ear
eas
to s
elec
tive
sero
toni
n re
-upt
ake
inhi
bito
rs (
SSR
I) o
r do
pam
ine
anta
goni
sts.
Bus
piro
ne, S
SRI,
or
dopa
min
e ag
onis
ts c
an n
otco
mpe
te w
ith A
cam
pros
ate
or o
pioi
d bl
ocke
rs a
s fa
r as
red
uctio
n of
alco
hol c
ravi
ng a
nd c
onsu
mpt
ion
are
conc
erne
d.
Mas
on B
J, O
wnb
y R
L.
Aca
mpr
osat
e fo
r th
etr
eatm
ent o
f al
coho
lde
pend
ence
: A r
evie
w o
fdo
uble
-blin
d, p
lace
bo-
cont
rolle
d tr
ials
. CN
SSp
ectr
ums.
200
0; 5
(2):
58-
Not
repo
rted
. St
udie
s w
ere
excl
uded
if th
eyin
volv
edsu
bjec
ts w
how
ere
preg
nant
,ha
d se
riou
sm
edic
al
Not
repo
rted
. 16 co
ntro
lled
clin
ical
tria
lsco
nduc
ted
acro
ss 1
1E
urop
ean
coun
trie
s.
Men
and
wom
en w
how
ere
alco
hol
depe
nden
t.
14 o
f th
e 16
stu
dies
fou
nd a
lcoh
ol-d
epen
dent
pat
ient
s tr
eate
d w
ithA
cam
pros
ate
had
a si
gnif
ican
tly
grea
ter
rate
of
tr
eatm
ent
com
plet
ion,
tim
e to
fir
st d
rink
, ab
stin
ence
rat
e, a
nd/o
r cu
mul
ativ
eab
stin
ence
du
rati
on
than
pa
tien
ts
trea
ted
wit
h pl
aceb
o.
T
hem
ultin
atio
nal s
tudy
was
fou
nd to
be
equa
lly e
ffec
tive
acro
ss 4
maj
orps
ycho
soci
al
conc
omita
nt
trea
tmen
t pr
ogra
ms
in
mai
ntai
ning
abst
inen
ce a
nd r
educ
ing
cons
umpt
ion
duri
ng a
ny p
erio
ds o
f re
laps
e.
116
69.
diso
rder
s, a
ndus
ed m
edic
atio
nli
kely
to a
ffec
tst
udy
outc
omes
.
Mat
tick
RP
, Jar
vis
T. A
sum
mar
y of
reco
mm
enda
tions
for
the
man
agem
ent o
f al
coho
lpr
oble
ms:
the
qual
ityas
sura
nce
in th
e tr
eatm
ent o
fdr
ug d
epen
denc
e pr
ojec
t.D
rug
and
Alc
ohol
Rev
iew
.19
94; 1
3: 1
45-5
5.
Not
repo
rted
Not
rep
orte
d N
otre
port
ed N
ot r
epor
ted
Not
rep
orte
d W
here
ass
essm
ent o
r pr
evio
us f
ailu
res
in tr
eatm
ent s
ugge
st th
ene
ed, l
onge
r ou
t-pa
tient
inte
rven
tion
exte
nded
ove
r m
ultip
lese
ssio
ns w
ill b
e re
quir
ed.
In-p
atie
nt/r
esid
entia
l and
day
pat
ient
inte
rven
tion
s fo
r th
e m
ost s
erio
usly
aff
ecte
d an
d de
pend
ent
indi
vidu
als
are
reco
mm
ende
d.
McC
rady
B S
Alc
ohol
use
diso
rder
s an
d th
e D
ivis
ion
12 T
ask
Forc
e of
the
Am
eric
an P
sych
olog
ical
Ass
ocia
tion,
Psy
chol
ogy
ofA
ddic
tive
Beh
avio
urs
2000
14(3
) : 2
67-2
76
Not
repo
rted
Publ
ishe
dst
udie
s re
port
ing
posi
tive
find
ings
Yes
62 s
tudi
es o
fal
l tre
atm
ent
type
s of
whi
ch 5
wer
e re
laps
epr
even
tion
.
Var
ious
Thi
s pa
per
revi
ews
alco
hol t
reat
men
t stu
dies
aga
inst
the
guid
elin
esof
the
Tas
k F
orce
. N
o tr
eatm
ent f
or a
lcoh
ol a
buse
or
depe
nden
ceha
d be
en r
ated
as
effi
caci
ous
by th
e T
ask
For
ce.
Thi
s st
udy
find
sth
at b
rief
inte
rven
tions
and
rel
apse
pre
vent
ion
do m
eet t
he c
rite
ria
but t
hat i
nsuf
fici
ent s
tudi
es h
ad b
een
publ
ishe
d w
hen
the
Tas
kFo
rce
list w
as p
ublis
hed.
Mon
ahan
SC
, Fin
ney
JW.
Exp
lain
ing
abst
inen
ce r
ates
follo
win
g tr
eatm
ent f
oral
coho
l abu
se: A
quan
titat
ive
synt
hesi
s of
pati
ent,
rese
arch
des
ign
and
trea
tmen
t eff
ects
. Add
icti
on19
96; 9
1(6)
: 787
-805
.
Not
repo
rted
Stud
ies
wer
ein
clud
ed if
they
repo
rted
trea
tmen
t gro
upou
tcom
e in
term
sof
abs
tine
nce;
had
a m
inim
umfo
llow
-up
poin
tof
at l
east
3m
onth
s; a
ndre
port
ed d
ata
onpa
tient
s’ m
arita
lan
d/or
empl
oym
ent
stat
us. S
tudi
esw
ere
excl
uded
ifth
ey c
ompr
ised
Not
repo
rted
100
stud
ies
prov
ided
data
for
the
anal
ysis
.
Not
repo
rted
. T
his
pape
r re
port
s a
stat
isti
cal r
egre
ssio
n an
alys
is a
imed
at
iden
tify
ing
fact
ors
that
exp
lain
dif
fere
nces
in a
bsti
nenc
e ra
tes.
Tre
atm
ent c
hara
cter
isti
cs w
ere
rela
ted
to a
bsti
nenc
e ra
tes:
mor
ein
tens
ive
trea
tmen
ts h
ad h
ighe
r ab
stin
ence
rat
es th
an le
ss in
tens
ive
trea
tmen
ts, w
here
as tr
eatm
ents
wit
h an
exp
ress
ed g
oal o
ther
than
abst
inen
ce h
ad lo
wer
abs
tine
nce
rate
s th
an tr
eatm
ents
wit
h an
abst
inen
ce g
oal.
Whe
n th
e pu
blic
ver
sus
priv
ate
owne
rshi
p st
atus
of
the
trea
tmen
t fac
ility
was
take
n in
to a
ccou
nt, t
he p
rese
nce
ofbe
havi
oura
l ele
men
ts in
the
trea
tmen
t con
ditio
n al
so w
as r
elat
ed to
high
er a
bstin
ence
rat
es.
Tre
atm
ent c
ondi
tions
with
a h
ighe
rpr
opor
tion
of s
ocia
lly s
tabl
e pa
tient
s ha
d be
tter
outc
omes
. R
esea
rch
desi
gn c
hara
cter
isti
cs w
ere
also
rel
ated
to a
bsti
nenc
e ra
tes.
Tre
atm
ent c
ondi
tions
with
sho
rter
fol
low
-ups
and
trea
tmen
ts d
raw
nfr
om s
tudi
es th
at d
id n
ot u
se c
rite
ria
to e
xclu
de m
ore
impa
ired
subj
ects
had
bet
ter
outc
omes
. Fu
ture
pri
mar
y st
udie
s ca
n de
term
ine
whe
ther
dif
fere
nces
in tr
eatm
ent i
nten
sity
of
the
mag
nitu
deex
amin
ed h
ere
are
link
ed to
dif
fere
nces
in a
bsti
nenc
e ra
tes
and
117
no-
or m
inim
al-
trea
tmen
t con
trol
grou
ps.
othe
r ou
tcom
e va
riab
les.
Nat
iona
l Ins
titut
e on
Alc
ohol
Abu
se a
ndA
lcoh
olis
m, 1
0th S
peci
alR
epor
t to
the
US
Con
gres
son
Alc
ohol
and
Hea
lth
June
2000
Ps
ycho
soci
al a
nd p
harm
acol
ogic
al in
terv
enti
ons
are
cons
ider
ed to
be c
ompl
emen
tary
. Ps
ycho
soci
al in
terv
entio
ns.
Cog
nitiv
e-be
havi
oura
l the
rapy
,m
otiv
atio
nal e
nhan
cem
ent a
nd 1
2 st
ep f
acili
tatio
n sh
own
to b
eab
out t
he s
ame
effe
ctiv
enes
s. C
lien
t-tr
eatm
ent m
atch
ing
does
not
seem
to a
dd e
ffec
tive
ness
. S
uppo
rtiv
e co
unse
llin
g (o
n ot
her
issu
es)
has
som
e ad
ditio
nal b
enef
it in
kee
ping
pat
ient
s in
trea
tmen
t lon
ger.
Mor
e in
tens
ive
trea
tmen
t giv
es b
ette
r sh
ort-
term
out
com
es b
ut lo
ngte
rm o
utco
mes
are
abo
ut th
e sa
me.
Phar
mac
olog
ical
inte
rven
tion
s. N
altr
exon
e an
d ac
ampr
osat
e ha
vebo
th b
een
show
n to
del
ay r
etur
n to
dri
nkin
g. S
epar
ate
and
com
bine
d us
e of
thes
e dr
ugs
is u
nder
inve
stig
atio
n. T
reat
men
t of
co-e
xist
ing
psyc
hiat
ric
cond
ition
s, e
spec
ially
dep
ress
ion,
impr
oves
outc
omes
. S
SR
Is h
ave
no e
ffec
t for
alc
ohol
dep
ende
nt p
atie
nts
and
a m
ild, t
rans
ient
eff
ect i
n m
oder
ate
drin
kers
. T
reat
men
t cos
ts.
Out
pati
ent t
reat
men
t is
mor
e co
st-e
ffec
tive
for
mos
t pat
ient
s. L
onge
r in
patie
nt s
tay
has
not b
een
show
n to
be
cost
-ef
fect
ive.
Lon
g-te
rm c
osts
are
not
aff
ecte
d by
set
ting
or
inte
nsit
y. O
’Con
nor
PG
, Sch
otte
nfie
ldR
S. P
atie
nts
with
alc
ohol
prob
lem
s. N
ew E
ngla
ndJo
urna
l of
Med
icin
e 19
98;
338(
9): 5
92-6
02.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
Not
rep
orte
d N
ot r
epor
ted
Thi
s is
a g
ener
al r
evie
w o
f tr
eatm
ent a
reas
. O
n re
laps
e pr
even
tion
,ci
tes
stud
ies
in s
uppo
rt o
f ps
ycho
soci
al in
terv
entio
ns a
nd a
djun
ctiv
eph
arm
acot
hera
pies
, als
o re
view
ed e
lsew
here
.
O’M
alle
y SS
. Opi
oid
anta
goni
sts
in th
e tr
eatm
ent
of a
lcoh
ol d
epen
denc
e:cl
inic
al e
ffic
acy
and
prev
entio
n of
rel
apse
.A
lcoh
ol a
nd A
lcoh
olis
m19
96; 3
1(Su
ppl 1
): 7
7-81
Not
repo
rted
Not
rep
orte
d N
otre
port
ed 5
effi
cacy
stud
ies,
3 o
fw
hich
als
ore
port
ed in
Gar
butt
et a
l.
Hea
vydr
inke
rs o
ral
coho
lde
pend
ent.
Var
ious
popu
latio
ngr
oups
.
Rev
iew
s sm
all-
scal
e tr
ials
that
gen
eral
ly s
uppo
rt u
se o
f op
ioid
anta
goni
sts
in c
ombi
natio
n w
ith a
ran
ge o
f ps
ycho
soci
alin
terv
entio
ns.
Smith
JE
et a
l, T
heco
mm
unit
y re
info
rcem
ent
appr
oach
to th
e tr
eatm
ent o
fsu
bsta
nce
use
diso
rder
s.
Not
repo
rted
Not
rep
orte
d N
otre
port
ed 3
rece
ntm
eta
anal
yses
Var
ious
The
com
mun
ity
rein
forc
emen
t app
roac
h (C
RA
) ha
s a
num
ber
ofdi
ffer
ent c
ompo
nent
s, in
clud
ing
beha
viou
ral c
oupl
es c
ouns
ellin
gan
d jo
b cl
ubs.
Reg
ardl
ess
of th
e m
anne
r in
whi
ch th
e m
eta
anal
yses
wer
e co
nduc
ted,
the
find
ings
con
sist
ently
sug
gest
ed th
at C
RA
was
118
The
Am
eric
an J
ourn
al o
nA
ddic
tions
, 200
1 10
(S)
: 51-
59
effe
ctiv
e. C
RA
is a
rel
ativ
ely
inex
pens
ive
trea
tmen
t app
roac
h.
Swif
t RM
. Dru
g th
erap
y:D
rug
ther
apy
for
alco
hol
depe
nden
ce. N
ew E
ngla
ndJo
urna
l of
Med
icin
e 19
99;
340(
19):
148
2-90
.
Not
repo
rted
. St
udie
s in
clud
edw
ere
all d
oubl
e-bl
ind,
pla
cebo
-co
ntro
lled
clin
ical
tria
ls.
Not
repo
rted
Not
rep
orte
d N
otre
port
ed.
Gen
eral
rev
iew
of
drug
ther
apy
for
alco
hol d
epen
dent
pat
ient
s. D
isul
fira
m.
Pla
cebo
con
trol
led
clin
ical
tria
ls h
ave
been
inco
nclu
sive
. M
ay b
e a
psyc
holo
gica
l det
erre
nt to
dri
nkin
g. C
alci
um c
arbi
mid
e. N
o m
ore
effe
ctiv
e th
an p
lace
bo in
cli
nica
ltr
ials
. W
ithdr
awn
from
the
mar
ket b
y m
anuf
actu
rer.
Opi
oid
anta
goni
sts.
Sev
eral
dou
ble-
blin
d, p
lace
bo-c
ontr
olle
d tr
ials
have
fou
nd th
at n
altr
exon
e is
eff
icac
ious
whe
n co
mbi
ned
wit
hps
ycho
soci
al tr
eatm
ents
. So
me
stud
ies
have
fou
nd n
o ef
fect
but
of
thes
e on
e w
as p
roba
bly
too
smal
l and
two
invo
lved
mul
tiple
subs
tanc
e ab
use.
Ano
ther
stu
dy f
ound
an
effe
ct in
pat
ient
s w
hoto
ok a
t lea
st 8
0% o
f th
e pr
escr
ibed
med
icat
ion.
Aca
mpr
osat
e. R
evie
ws
3 tr
ials
whi
ch a
re r
epre
sent
ativ
e; 2
sho
wac
ampr
osat
e to
be
effe
ctiv
e an
d 1
foun
d no
eff
ect i
n m
ildl
yde
pend
ent p
atie
nts.
Dop
amin
e an
tago
nist
s. T
iapi
de h
as b
een
show
n to
be
effe
ctiv
e in
com
plia
nt p
atie
nts.
Res
ults
for
bro
moc
ript
ine
are
equi
voca
l. O
ther
dru
gs (
lithi
um, c
arba
maz
epin
e, b
enzo
diaz
epin
es a
nd S
SRIs
)ha
ve n
ot b
een
show
n to
be
effe
ctiv
e in
rel
apse
pre
vent
ion.
Psyc
hiat
ric
com
orbi
dity
sho
uld
be tr
eate
d w
ith
drug
s th
at a
reef
fect
ive
for
the
psyc
hiat
ric
cond
ition
. Q
uest
ions
rem
ain
abou
t the
opt
imal
dru
g do
sage
, the
dur
atio
n of
trea
tmen
t, co
ncom
itan
t psy
chos
ocia
l the
rapy
, the
cos
t of
effe
ctiv
enes
s of
dru
g th
erap
y, a
nd th
e ty
pes
of p
atie
nts
who
will
bene
fit m
ost f
rom
a s
peci
fic
drug
Thu
rber
S E
ffec
t siz
ees
tim
ates
in c
hem
ical
aver
sion
trea
tmen
ts o
fal
coho
lism
. Jou
rnal
of
Clin
ical
Psy
chol
ogy
1985
;41
(2):
285
-287
Not
repo
rted
Incl
uded
hum
anst
udie
s w
ithor
igin
al d
ata,
cont
rol o
rco
mpa
riso
ngr
oups
and
stat
istic
s su
itabl
efo
r m
eta-
anal
ysis
.
Not
repo
rted
6 st
udie
s m
etth
e in
clus
ion
crite
ria
Not
rep
orte
d A
vers
ive
agen
ts
stud
ied
wer
e lit
hium
ca
rbon
ate,
em
etin
e an
dsc
olin
e.
Eff
ect
size
s w
ere
mod
est.
Few
stu
dies
wer
e av
aila
ble
com
pari
ng a
vers
ive
agen
ts w
ith
plac
ebo
or a
lter
nati
ve in
terv
enti
ons.
Thi
s st
udy
pred
ates
the
intr
oduc
tion
of
anti
-cra
ving
ther
apie
s.
Ton
igan
JS,
Tos
cova
R,
Yes
Stud
ies
wer
e Y
es 74
stu
dies
Var
ious
Thi
s re
view
was
con
cern
ed w
ith
the
effe
ct o
f sa
mpl
e ch
arac
teri
stic
s
119
Mill
er W
R. M
eta-
anal
ysis
of
the
liter
atur
e on
Alc
ohol
ics
Ano
nym
ous:
Sam
ple
and
stud
y ch
arac
teri
stic
sm
oder
ate
find
ings
. Jou
rnal
of S
tudi
es o
n A
lcoh
ol 1
996;
57(1
): 6
5-72
.
excl
uded
if th
ere
port
was
pure
ly n
arra
tive;
com
bine
dal
coho
l and
othe
r su
bsta
nce
abus
e cl
ient
s;da
ta r
epor
ting
was
inad
equa
te;
AA
and
Nar
cotic
sA
nony
mou
ssa
mpl
es w
ere
com
bine
d.
popu
latio
ngr
oups
.an
d st
udy
qual
ity o
n th
e ef
fect
iven
ess
resu
lts f
or A
A.
The
stu
dyqu
ality
of
57 o
f th
e 74
stu
dies
wer
e re
port
ed a
s be
ing
“poo
r” a
ndth
ey w
ere
larg
ely
non-
expe
rim
enta
l in
desi
gn.
Find
ings
wer
e hi
ghly
vari
able
acr
oss
the
stud
ies
and
part
of
this
var
iabi
lity
was
exp
lain
edby
sam
ple
char
acte
rist
ics.
A
A p
artic
ipat
ion
and
drin
king
out
com
esw
ere
mor
e st
rong
ly
rela
ted
in
outp
atie
nt
sam
ples
, an
d be
tter
desi
gned
stu
dies
wer
e m
ore
likel
y to
rep
ort
posi
tive
psyc
hoso
cial
outc
omes
rel
ated
to
AA
att
enda
nce.
AA
exp
erie
nces
and
out
com
esar
e he
tero
gene
ous,
and
it m
akes
littl
e se
nse
to s
eek
omni
bus
prof
iles
of A
A a
ffili
ates
or
outc
omes
. W
ell-
desi
gned
stu
dies
with
lar
geou
tpat
ient
sa
mpl
es
may
af
ford
th
e be
st
oppo
rtun
ity
to
dete
ctpr
edic
tors
and
eff
ects
of
AA
invo
lvem
ent.
Wal
ters
GD
. Beh
avio
ural
self
-con
trol
trai
ning
for
prob
lem
dri
nker
s: A
met
a-an
alys
is o
f ra
ndom
ised
cont
rol s
tudi
es. B
ehav
iour
The
rapy
. 200
0; 3
1: 1
35-4
9.
Yes
, key
-w
ords
used
wer
elis
ted.
Not
rep
orte
d. Y
es.
17 R
CT
s. Pe
ople
who
wer
e al
coho
lde
pend
ent o
rpr
oble
mdr
inke
rs.
Beh
avio
ural
se
lf-c
ontr
ol
trai
ning
m
et
wit
h gr
eate
r su
cces
s th
anab
stin
ence
-ori
ente
d in
terv
entio
n at
a
leve
l th
at
bord
ered
on
stat
istic
al s
igni
fica
nce
in f
ollo
w-u
ps l
astin
g a
year
or
long
er (
n=5;
d=0.
35;
SE=
0.18
; 95
% C
I=0.
00 t
o 0.
70).
B
ehav
iour
al s
elf-
cont
rol
trai
ning
w
as
supe
rior
to
no
in
terv
entio
n an
d al
tern
ativ
e no
n-ab
stin
ence
-ori
ente
d in
terv
enti
ons
in
redu
cing
bo
th
alco
hol
cons
umpt
ion
and
prob
lem
atic
dri
nkin
g.
The
res
ults
als
o fa
vour
edbe
havi
oura
l sel
f-co
ntro
l tra
inin
g ov
er tr
aditi
onal
abs
tinen
ce-o
rien
ted
trea
tmen
t, bu
t th
e ef
fect
siz
e fe
ll s
hort
of
stat
isti
cal
sign
ific
ance
.A
llow
ing
clie
nts
to c
hoos
e fr
om a
mon
g se
vera
l op
tions
, ab
stin
ence
as
wel
l as
co
ntro
lled
dr
inki
ng,
may
pr
ove
mor
e ef
fect
ive
than
forc
ing
them
in
to
stan
dard
ised
tr
eatm
ent
prot
ocol
, as
re
sear
chin
dica
ted
that
sup
erio
r ou
tcom
es a
re o
ften
ach
ieve
d w
hen
prob
lem
-dr
inki
ng
clie
nts
are
offe
red
a go
al-c
hoic
e op
tion
ea
rly
in
the
inte
rven
tion
proc
ess.
Wil
de M
I. W
agst
aff
AJ.
Aca
mpr
osat
e: A
rev
iew
of
its
phar
mac
olog
y an
dcl
inic
al p
oten
tial i
n th
em
anag
emen
t of
alco
hol
depe
nden
ce a
fter
deto
xifi
catio
n. D
rugs
. 199
7;53
(6):
103
8-53
.
Not
repo
rted
Non
-co
mpa
rati
vetr
ials
wer
eex
clud
ed f
rom
the
revi
ew.
Not
repo
rted
Det
ails
of
8st
udie
s ar
epr
ovid
ed.
Apo
oled
anal
ysis
of
11 tr
ials
(inc
ludi
ngso
me
of th
e
Men
and
wom
en w
hoar
e al
coho
lde
pend
ent.
The
res
ults
fro
m t
he p
oole
d an
alys
is o
f da
ta f
rom
11
doub
le-b
lind
rand
omis
ed 3
- to
12-
mon
th p
lace
bo-c
ontr
olle
d tr
ials
of
acam
pros
ate
foun
d, a
ccor
ding
to
inte
ntio
n-to
-tre
at a
naly
sis,
abs
tine
nce
rate
s (6
7vs
54
%),
pa
tient
at
tend
ance
(5
0 vs
. 40
%)
and
perc
enta
ge
ofab
stin
ent
days
(4
9 vs
. 40
%)
wer
e si
gnif
ican
tly
grea
ter
wit
hac
ampr
osat
e th
an w
ith
plac
ebo.
D
urin
g th
e fi
rst
12 m
onth
s af
ter
alco
hol d
etox
ific
atio
n, p
atie
nts
wit
h al
coho
l dep
ende
nce
are
at h
igh-
risk
of
rela
pse.
Fin
ding
s in
this
rev
iew
sug
gest
that
rel
apse
rat
es a
re
120
8 st
udie
sal
read
yre
port
ed)
was
car
ried
out.
high
er t
han
50%
dur
ing
the
firs
t ye
ar.
In
cont
rast
to
man
y ot
her
trea
tmen
t app
roac
hes
for
alco
hol-
depe
nden
t pat
ient
s, a
cam
pros
ate
isge
nera
lly w
ell t
oler
ated
. A
cam
pros
ate,
as
an
ad
junc
t to
ps
ycho
soci
al
and
beha
viou
ral
appr
oach
es,
seem
s a
prom
isin
g ad
vanc
e fo
r m
aint
aini
ng a
bsti
nenc
ein
alc
ohol
-dep
ende
nt p
atie
nts
duri
ng t
he p
ost-
alco
hol
with
draw
alpe
riod
.
121
Tab
le10
.10
Sum
mar
y of
Rel
apse
Pre
vent
ion
Cos
t-E
ffec
tive
ness
Stu
dies
Rev
iew
ed St
udy
Typ
e of
Ana
lysi
s Po
pula
tion
Inte
rven
tion
Out
com
es R
esul
ts
Ann
eman
s L
et a
l.E
cono
mic
eva
luat
ion
of c
ampr
al(a
cam
pros
ate)
com
pare
d to
pla
cebo
in m
aint
aini
ngab
stin
ence
in a
lcoh
olde
pend
ent p
atie
nts.
Eur
opea
n A
ddic
tion
Res
earc
h. 2
000;
6:7
1-8.
Part
ial
Eva
luat
ion/
Mod
ellin
g
Hyp
othe
tical
coho
rt o
f w
eane
dB
elgi
an a
lcoh
olic
s
Aca
mpr
osat
e in
hel
ping
mai
ntai
nab
stin
ence
Tre
amen
t cos
ts a
nd h
ealt
hca
re c
ost s
avin
gs T
otal
exp
ecte
d co
st f
or a
cam
pros
ate
stra
tegy
is21
1,98
6BE
F co
mpa
red
to 2
33,2
87B
EF
for
the
’no
trea
tmen
t’ st
rate
gy.
App
ears
that
acam
pros
ate
is c
ost-
savi
ng to
the
heal
th c
are
prov
ider
. A
vera
ge n
et s
avin
gs a
re 2
2,00
0 B
EF
per
patie
nt o
ver
24 m
onth
s.
Cis
ler
et a
l A
ctua
lan
d re
plic
ated
cos
tsfo
r al
coho
l tre
atm
ent
mod
aliti
es: C
ase
stud
y fr
om P
roje
ctM
AT
CH
, Jou
rnal
of
Stud
ies
on A
lcoh
ol19
98 (
59)
: 503
-12
Cos
t
Proj
ect M
AT
CH
Cos
ts o
f th
e Pr
ojec
t MA
TC
Hth
erap
ies
– C
ogni
tive
Beh
avio
ural
The
rapy
, Mot
ivat
iona
lE
nhan
cem
ent T
hera
py a
nd 1
2St
ep F
acili
tatio
n
No
heal
th o
r w
ider
cons
eque
nces
. T
reat
men
tco
sts
Proj
ect M
AT
CH
ther
apie
s sh
ow m
ean
cost
s of
ME
T to
be
$498
per
hou
r, C
BT
to b
e $1
98/h
our
and
TSF
at $
253.
Per
par
ticip
ant c
osts
sho
w th
em
ean
TSF
cos
t of
$170
0, C
BT
mea
n=$1
901
and
TSF
=$1
969.
Hol
der,
HD
, Cis
ler,
RA
, Lon
gaba
ugh,
R,
Stou
t, R
L, T
reno
, AJ
Zw
eben
, AA
lcoh
olis
m tr
eatm
ent
and
med
ical
car
eco
sts
from
Pro
ject
MA
TC
H, A
ddic
tion
,20
00 9
5 (7
); 9
99-
1013
.
27
9 Pr
ojec
tM
AT
CH
part
icip
ants
at t
wo
MA
TC
H c
linic
alre
sear
ch u
nits
The
res
ults
sho
w h
ealt
h ca
re c
ost s
avin
gs to
be
depe
nden
t upo
n th
e ke
y pa
tien
t cha
ract
eris
tics
of a
lcoh
ol d
epen
denc
e, p
sych
iatr
ic s
ever
ity
and
the
leve
l of
netw
ork
supp
ort f
or d
rink
ing.
The
ME
T tr
eatm
ent a
ppea
rs m
ost l
ikel
y to
gen
erat
eco
st s
avin
gs in
pat
ient
s w
ith lo
w p
sych
iatr
icse
veri
ty a
nd lo
w n
etw
ork
supp
ort f
or d
rink
ing,
whi
lst f
or th
e m
ost s
ever
e pa
tient
s in
thes
e tw
ogr
oups
, CB
T g
ener
ates
gre
ater
sav
ings
. Fo
rpa
tient
s w
ith h
igh
leve
ls o
f al
coho
l dep
ende
nce,
the
TSF
trea
tmen
t pro
duce
s gr
eate
r he
alth
car
eco
st s
avin
gs.
McC
rady
B e
t al.
Eco
nom
ic A
lcoh
olic
s af
ter
Part
ial h
ospi
talis
atio
n. H
ospi
tal
Dri
nkin
g qu
antit
y, Q
uant
ity-
Tot
al tr
eatm
ent c
osts
wer
e lo
wer
for
the
PHT
122
Cos
t eff
ecti
vene
ss o
fal
coho
lism
trea
tmen
tin
par
tial h
ospi
tal
vers
us in
patie
ntse
tting
s af
ter
brie
fin
patie
nt tr
eatm
ent:
12 m
onth
out
com
es.
Jour
nal o
f C
onsu
lting
and
Clin
ical
Psyc
holo
gy. 1
986;
54(5
): 7
08-1
3.
Eva
luat
ion
inpa
tient
trea
tmen
t and
/or
deto
xifi
catio
n.Pa
tient
s w
ere
inne
ed o
fde
toxi
fica
tion
orin
tens
ive
inpa
tient
care
, and
diag
nose
d as
an
alco
hol a
buse
r or
alco
hol
depe
nden
t. 17
4al
coho
lics.
PHT
:114
, EIP
:60
deto
x th
en c
omm
uted
to h
ospi
tal
from
hom
e fo
r 6.
5 ho
urs
a da
yve
rsus
inpa
tient
trea
tmen
t -co
ntin
ued
as in
patie
nts
but w
ent
into
sam
e pr
ogra
mm
e as
the
part
ial p
atie
nts.
Freq
uenc
y A
naly
sis,
Dri
nkin
g da
ys/m
onth
, Leg
alpr
oble
ms,
fre
quen
cy a
ndpr
oble
m c
onse
quen
ces,
inco
me
from
mis
sing
wor
k,ch
ild
care
dur
ing
hosp
italis
atio
n.
grou
p co
mpa
red
to th
e E
IP g
roup
. In
itial
trea
tmen
t cos
ts w
ere
$170
0 lo
wer
for
PH
T,
outp
atie
nt a
nd r
ehos
pita
lisat
ion
cost
s w
ere
com
para
ble.
PH
T g
roup
mos
t lik
ely
to b
eho
spita
lised
at o
ther
fac
ilitie
s. U
nit c
osts
of
impr
ovem
ent d
efin
ed b
y di
ffer
ence
bet
wee
nba
selin
e an
d fo
llow
-up
abst
inen
t day
s di
vide
d by
tota
l tre
atm
ent c
osts
, to
give
abs
tinen
t day
s pe
r$1
00 in
vest
ed.
PHT
= 5
.4 d
ays/
$100
and
EIP
=4.
2 da
ys/$
100.
Tre
atm
ent c
ost p
er a
bstin
ent
subj
ect =
$18
,935
(PH
T)
and
$21,
637
(EIP
).T
otal
trea
tmen
t cos
t per
abs
tinen
t or
mod
erat
edr
inki
ng s
ubje
ct =
$99
66 (
PHT
) an
d $1
3222
(EIP
) O
’Far
rell
TJ
et a
l.C
ost-
bene
fit a
nd c
ost-
effe
ctiv
enes
s an
alys
esof
beh
avio
ural
mar
ital
ther
apy
with
and
with
out r
elap
sepr
even
tion
sess
ions
for
alco
holi
cs a
ndth
eir
spou
ses.
Beh
avio
ur T
hera
py.
1996
a); 2
7:7-
24.
Eco
nom
icev
alua
tion
59 c
oupl
es w
ithan
alc
ohol
ichu
sban
d (U
SA)
Rel
apse
pre
vent
ion
as a
n ad
junc
tto
beh
avio
ural
mar
ital t
hera
py Sa
ving
s in
hea
lth
care
and
lega
l sys
tem
cos
ts B
MT
mor
e co
st-e
ffec
tive
than
BM
T p
lus
RP
inte
rms
of p
erce
ntag
e of
day
s ab
stin
ent,
whe
nas
sess
ed b
y pe
rcen
tage
of
days
abs
tinen
t poe
r$1
00 s
pent
(7%
impr
ovem
ent v
ersu
s 4%
impr
ovem
ent p
er $
100
trea
tmen
t cos
ts).
BM
T -
Mon
etar
y co
sts
of h
ealth
and
lega
l sys
tem
utili
satio
n re
duce
d by
an
aver
age
$420
0 pe
rpa
tient
, com
pare
d w
ith $
1,25
9 av
erag
e co
sts
oftr
eatm
ent.
Com
pari
ng B
MT
and
BM
T p
lus
RP,
the
mon
etar
y va
lue
of b
enef
its m
inus
trea
tmen
tco
sts
wer
e $4
,189
and
$1,
725
resp
ectiv
ely.
O’F
arre
ll T
J et
al.
Cos
t-be
nefi
t and
cos
t-ef
fect
iven
ess
anal
yses
of b
ehav
iour
al m
arita
lth
erap
y as
an
addi
tion
to o
utpa
tient
alco
holi
sm tr
eatm
ent.
Jour
nal o
f Su
bsta
nce
Abu
se. 1
996b
; 8(2
):14
5-66
.
Eco
nom
icE
valu
atio
n(C
EA
and
CB
A)
36 m
arri
ed m
ale
alco
holi
cs w
hoha
d st
arte
din
divi
dual
ther
apy,
Vet
eran
sA
ffai
rs C
ente
r,U
SA
Indi
vidu
al c
ouns
ellin
g al
one
(n=
12),
cou
nsel
ling
plus
BM
T(n
=10
), o
r co
unse
lling
with
an
inte
ract
iona
l cou
ples
gro
up(n
=12
)
Hea
lth
serv
ice
cost
sav
ings
,le
gal s
yste
m s
avin
gs, h
ealth
impr
ovem
ents
Mon
etar
y be
nefi
t of
redu
ced
Hea
lth
and
Leg
alco
sts
coun
selli
ng p
lus
BM
T =
$66
81,
coun
selli
ng p
lus
inte
ract
iona
l = -
$224
8,co
unse
lling
alo
ne =
$75
81: M
onet
ary
bene
fits
min
us tr
eatm
ent d
eliv
ery
cost
$58
24, -
$314
3,$7
131.
Ben
efit-
to-c
ost-
ratio
8.6
4, -
2.82
, 20.
77.
Gre
ates
t sav
ings
thro
ugh
coun
selli
ng a
lone
.C
ost-
effe
ctiv
enes
s an
alys
is: i
mpr
ovem
ent i
npe
rcen
t day
s ab
stin
ent p
er $
100
of p
rogr
amm
eex
pend
itur
e fr
om p
re-t
reat
men
t to
one
year
follo
w u
p, in
divi
dual
cou
nsel
ling
plus
BM
Tyi
elds
5.4
day
s im
prov
emen
t per
$10
0 in
vest
ed,
123
indi
vidu
al c
ouns
ellin
g pl
us in
tera
ctio
nal t
hera
pyyi
elds
4.3
day
s an
d in
divi
dual
cou
nsel
ling
only
gene
rate
s 13
.6. C
ost t
o pr
oduc
e on
e co
ntin
ually
abst
inen
t par
ticip
ant f
or o
ne y
ear,
cou
nsel
ling
alon
e :$
1,35
0, c
ouns
elli
ng p
lus
inte
ract
iona
lth
erap
y: $
3,58
0 an
d co
unse
llin
g pl
us B
MT
:$2
,143
. Res
ults
sug
gest
cou
nsel
ling
alon
e to
be
the
mos
t cos
t-ef
fect
ive
trea
tmen
t. L
imit
ed s
tudy
:Sm
all s
ampl
e si
zes
Petti
nati
HM
et a
l.In
patie
nt a
lcoh
oltr
eatm
ent i
n a
priv
ate
heal
thca
re s
ettin
g:W
hich
pat
ient
sbe
nefi
t and
at w
hat
cost
? T
he A
mer
ican
Jour
nal o
nA
ddic
tions
. 199
9;8:
220-
33.
Part
ial
eval
uatio
n 93
inpa
tient
s an
d80
out
patie
nts
in a
priv
ate
heal
th c
are
alco
hol
prog
ram
me,
USA
Clin
ical
pro
gram
me
base
d on
a12
-ste
p pr
ogra
mm
e of
AA
,in
divi
dual
, mar
ital,
fam
ily a
ndgr
oup
coun
selli
ng in
the
inte
nsiv
etr
eatm
ent p
erio
d of
4 w
eeks
of
inpa
tient
and
6 w
eeks
of
outp
atie
nt c
are.
Pro
gram
me
diff
eren
ces
cent
red
on a
mou
nt o
ftr
eatm
ent h
ours
and
att
enda
nce
atsu
ppor
t gro
ups.
Inp
atie
nts
atte
nded
ther
apy
duri
ng th
e da
yan
d A
A a
t eve
ning
s. O
utpa
tien
tsat
tend
ed s
essi
ons
appr
oxim
atel
y1-
2 ev
enin
gs a
wee
k, a
nd A
Am
eeti
ngs
on th
e ev
enin
gs th
at th
eydi
d no
t atte
nd th
erap
y se
ssio
ns,
and
a fa
mil
y ed
ucat
ion
prog
ram
me
duri
ng w
eeke
nds.
Var
ious
dri
nkin
g ou
tcom
es:
Inpa
tient
and
out
patie
nt c
osts
in a
’cos
t-of
fset
’ sce
nari
o
The
ave
rage
cos
t per
suc
cess
full
y co
mpl
etin
gin
patie
nt w
as $
9,01
4 an
d fo
r an
out
patie
nt,
$1,4
20.
Thi
s in
dica
tes
inpa
tient
trea
tmen
t cos
tsw
ere
appr
oxim
atel
y 6.
5 tim
es th
at o
f ou
tpat
ient
.T
he a
utho
rs c
alcu
late
a ’c
ost-
effe
ctiv
enes
s’ ra
tioat
thre
e, s
ix a
nd 1
2 m
onth
s fo
llow
up
as a
rat
ioof
inpa
tient
:out
patie
nt c
osts
and
fin
d th
e ra
tios
to b
e 4.
5:1,
5.3
:1 a
nd 5
.6:1
res
pect
ivel
y. T
heau
thor
s co
nclu
de th
at th
is is
a m
odes
t ’co
st-
offs
et’ e
ffec
t. A
lso
conc
lude
that
inpa
tient
mor
e ex
pens
ive
than
out
patie
nt d
espi
te b
ette
r ou
tcom
es.
Thi
sne
eds
furt
her
anal
ysis
as
to ’h
ow m
uch
mor
eex
pens
ive
per
unit
of o
utco
me’
. T
his
is n
otpr
ovid
ed.
Scha
dlic
h PK
, Bre
cht
JG. T
he c
ost
effe
ctiv
enes
s of
acam
pros
ate
in th
etr
eatm
ent o
fal
coho
lism
inG
erm
any.
Phar
mac
oeco
nom
ics.
1998
; 13(
6): 7
19-3
0.
Eco
nom
icE
valu
atio
nba
sed
onsi
mul
atio
n
5000
00al
coho
lics,
sim
ulat
ion
scen
ario
,G
erm
any
Adj
unct
aca
mpr
osat
e fo
r 48
day
sin
add
ition
to s
tand
ard
care
. B
oth
trea
tmen
ts to
ok p
lace
aft
er a
nal
coho
l det
ox a
nd b
efor
ead
mis
sion
into
the
stud
y th
epa
tient
s ha
d to
be
com
plet
ely
abst
inen
t for
a m
inim
um o
f 14
and
max
imum
of
28 d
ays.
Som
ede
tox
inpa
tient
bas
ed.
Abs
tinen
ce in
fol
low
up
peri
od, A
dver
se h
ealth
effe
cts
of a
lcoh
olde
pend
ence
syn
drom
e,al
coho
l psy
chos
es, a
lcoh
olic
fatty
live
r, a
cute
alc
ohol
iche
patit
is a
nd a
lcoh
olic
live
rci
rrho
sis
but t
hese
wer
e on
lyin
clud
ed in
the
anal
ysis
of
heal
th c
osts
avo
ided
.
Cos
t sav
ings
of
DM
2602
per
add
ition
alab
stin
ent p
atie
nt. T
here
are
issu
es a
bout
stan
dard
car
e an
d ho
w a
cam
pros
ate
can
bead
min
iste
red
at th
e id
eal p
erio
d w
hen
peop
leha
ve b
ecom
e fi
rst a
bstin
ent.
Stu
dy f
ails
toac
coun
t for
a n
umbe
r of
pot
entia
l ben
efits
fro
mtr
eatm
ent a
nd m
ain
outc
ome
is li
mite
d.
124
CHAPTER ELEVEN OTHER ISSUES
SUMMARY This chapter reviews other issues from the literature which were not categorised byintervention type. The main findings are• one study has produced a ranking of effectiveness evidence across treatment areas;• evidence relating to workplace interventions is mixed;• structured cognitive-behavioural interventions may be the most effective intervention in
prison settings but brief interventions may work with problem drinkers;• process of care may be an important factor in addressing specific populations groups, such
as women and the elderly;• training needs for general professional groups need to be addressed;• costs for a general treatment programme in Scotland are provided; and• cost-offsets from interventions vary with patient characteristics, such as age and sex.
INTRODUCTION 11.1 This chapter summarises literature that cuts across the interventions covered in theearlier chapters. The effectiveness reviews cover a study which has ranked interventionsacross a number of areas and studies relating to locations and specific population groupsrather than interventions. Also included are reviews dealing with educational requirements ofproviders. The cost-effectiveness study relates to a general treatment programme but is ofparticular interest as it was carried out in Scotland. The cost-offset studies cover similartopics to the effectiveness reviews. The studies reviewed are summarised briefly in tables11.3 (effectiveness) and 11.4 and 11.5 (cost studies) at the end of the chapter.
EFFECTIVENESS STUDIES
Ranking of effectiveness evidence across treatments 11.2 A study by Miller et al (1998) has attempted to produce an effectiveness rankingacross treatment areas (the so called “Mesa Grande”). The authors produced a cumulativeeffectiveness score (CES) for all interventions by weighting study outcomes by study qualityand summing the scores. Study quality is assessed on 12 dimensions and results in amaximum possible methodological quality score (MQS) of 17. Study outcomes were scoredas positive (+1) or strongly positive (+2), negative (-1) or strongly negative (-2). Theresulting CES is a useful indicator of whether the balance of the evidence is negative orpositive but as an indicator of the relative strength of evidence the comparison between scoresis less helpful. A higher score may simply reflect the fact that more studies have been carriedout for that intervention.
125
Table 11.1 Extract of results for cumulative effectiveness Intervention MQS N+ N- CES 5 highest scoring Brief interventions 12.68 19 9 +221 Motivational enhancement 13.31 10 3 +145 Social skills training 10.94 11 6 +120 Community reinforcement approach 13.25 4 0 +80 Acamprosate 12.00 3 0 +72 5 lowest scoring Relaxation training 10.81 3 13 -135 Confrontational counselling 11.67 0 9 -155 Psychotherapy 11.21 2 12 -163 General alcoholism counselling 11.2 2 17 -226 Educational lectures/films 9.68 4 27 -364
Source Miller et al 1998 11.3 The problem can be illustrated from the partial results reproduced in table 11.1. Briefinterventions achieve the highest CES based on 19 positive studies and 9 negative studies.However, Acamprosate is placed 5th with only 3 positive studies. The CES per study ishigher for Acamprosate than for brief interventions. There is no attempt to take into accountthe size of the effect that each intervention produces and the terminology used to describeinterventions is not always clear.
Location studies 11.4 A number of reviews have addressed the provision of alcohol misuse interventions inparticular settings. These reviews do not provide evidence about comparative effectivenessbetween the setting studied and other alternative settings. However, they may provide usefulinsights to the provision of services in these settings and possible models for interventionprogrammes. Workplace 11.5 Two reviews have considered workplace interventions based on US data relating toemployee assistance programmes (EAP) (Colantonio 1989; Roman and Blum 1996). Thesereviews do not provide very specific details of the interventions employed, althoughcounselling is reported as the most frequent intervention in one review. Both reviews reportpositive findings from the workplace interventions but based on poor study designs. On thisbasis, one author supports EAP and the other does not. The relevance to the UK of suchstudies may be limited.
126
Prisons 11.6 A comprehensive review of interventions in the context of prisons has been carriedout by McMurran (1995). The paper considers the issues raised by the characteristics of theclient population, by the setting and the nature of the goals set. Structured cognitive-behavioural programmes are seen to be most effective but brief interventions may also beeffective with problem drinkers. The author provides recommendations for an interventionprogramme for UK prisons based on the review of evidence.
Population groups 11.7 A number of reviews have considered the requirements of particular populationgroups with respect to alcohol misuse. Women 11.8 Gender differences in treatment outcome appear to be small, with women achievingbetter results in the first 12 months of follow up while men have better results thereafter(Jarvis 1992). Nevertheless, gender issues may affect the process and outcomes for women. Older people 11.9 Older adults are particularly susceptible to adverse medical outcomes from substanceabuse (Fingerhood 2000). Brief interventions by primary care providers can have a majorimpact on preventing medical morbidity and improving quality of life. Treatment modalitiesfor substance abuse in older people should be individualised to optimise success.
Education and training 11.10 Reviews of the education and training needs of professional groups also provide someuseful discussion of the potential roles for different professional groups. The studies do notprovide any information on the comparative effectiveness of professional groups, however.One general review considers whom to train and the content of courses (Roche 1998). Theauthor argues that training for generalists is as important as that for specialist workers andthat training should reflect the multi-disciplinary nature of the field. Nurses 11.11 A review of the content of nurse education relating to alcohol found few studies onthis topic (Arthur 1998). Relatively few hours were devoted to alcohol. Little attention wasgiven to the skills required for assessment and intervention with problem drinkers. There wasmore reliance on specialist post-registration courses. This raises issues about the potentialrole of general nursing staff.
127
General practitioners 11.12 McAvoy (2000) draws comparisons between the UK, where there is no systematicapproach to training related to alcohol problems, and the US and Australia, where asystematic approach has increased teaching hours related to alcohol problems. However,there is a lack of evidence relating the educational input to changes in medical behaviour andthe cost-effectiveness of alternative strategies needs to be considered.
COST-EFFECTIVENESS
General Treatment Evaluation 11.13 The SECCAT study (McKenna et al, 1996) was a partial evaluation which aimed toquantify the costs and consequences of alcohol treatment, an important input to policy debatewhen determining the level of resource input to tackling alcohol problems. In the SECCATstudy, a cohort of patients at the Alcohol Problems Clinic in Edinburgh were assessed forbasic demographic and resource use data. Average health care utilisation costs and healthrelated assessment instruments were used to assess the health and resource use changesfollowing treatment. The sample consisted of 586 clients, 75% male, with a mean age 46years. Of these, 76% had initial diagnosis of alcohol dependence and 21% of alcohol abuse.The treatment included various interventions at the APC, such as inpatient and outpatienttreatment, ranging from intensive supportive therapy with individual counselling todetoxification with group therapy. Also included were disulfiram therapy and anti-depressants and recommendation to make contact with other agencies.
Table 11.2 Treatment costs:SECCAT Clinic costs Unit cost• Individual counselling session, £36.25• Group counselling session, £3.65• In-patient stay at APC, £1422.30• Home visit by APC staff. £22.00 GP costs• Visit to GP
£7.62
• Practice nurse visit, £3.83• Visit from GP, £22.00• Visit from PN. £7.89 Other costs• Non-APC counselling,
£3.65
• Week in residential unit, £275.00• Outpatient visit, £29.50• Non-APC inpatient day, £200.00• Visit to A and E. £57.00
Source: McKenna et al (1996)
128
11.14 At follow up, 41 out of 212 patients had been abstinent over the whole 6 months.Nineteen patients had no days of complete abstinence. Patients show much worse healthcompared with population norms using SF36. The average APC treatment cost was £429.14,GP costs were £52.73, and 'other' costs £569.41. Average drug costs of £82.70 gave anaverage cost of treatment of £1133.98. 11.15 A shortcoming of the study is that costs and effects not combined as such. Theauthors divide the results into quartiles and show that the most abstinent group made less useof emergency care. For the other groups results are ambiguous, showing the middle quartilesusing more resources than the most and least abstinent. Mean health care costs were £1134,of which 38% were related to APC treatment. Mean total health service costs are quartile1=£783, quartile 2=£1443, quartile 3=£1446 and quartile 4=£862. For APC costs, thosecompletely abstinent or not at all abstinent over the 6 month period show the lowest costs.Regressions showed age was negatively related to average total cost but the explanatorypower of regressions was low. Alcohol dependent patients were shown to have a greater useof health service resources than alcohol abusers. High rates of absence from work andaccidents and legal contacts were recorded but these are not costed. Over 20% had had anaccident at home compared to 2-4% from GHS data as a population norm. 11.16 SECCAT is a very limited study based on observational data. The study does showthat alcohol clients have poor quality of life as measured by SF36. However, there arecomplexities between the sub groups as abusers have lower use of services than dependentpatients. Alcohol dependence may be more significant than abuse in generating costs.Therefore costs could be saved by preventing the progression from abuse to dependence. Thestudy results do show complexities within the patient group and resource use is related todiagnosis and clinical outcomes.
COST OFFSETS 11.17 A substantial body of literature regarding cost-offset effects is evident in the USA.The main hypothesis is based on patients' utilisation of health care being reduced followingalcohol treatment. Initially patients have a pre-treatment utilisation of health care whichexceeds the average use in the wider population. Once treatment is completed, utilisation ofhealth care is reduced, with the savings often exceeding the actual cost of the treatment.Several cost-offsets studies are outlined here, although their relevance to the UK is highlyquestionable as the size of any saving in health care utilisation will be very much smaller.
Treatment type and offset effects 11.18 Holder and Blose (1992) used a population of employees at a large mid-westernmanufacturing company to investigate the impact of alcohol treatment on total health carecosts. A longitudinal study design was used examining the records of employees filingclaims for alcohol treatment with the employer's insurance programme between 1974 and1987. A total of 3,729 alcoholics were identified, of which 3,068 received treatment. Thedata on employees receiving alcohol treatment were compared to a population with severealcohol related conditions but receiving no specific alcohol treatment. A multivariate analysiswas used to compare pre and post-treatment levels of health care.
129
11.19 Employees were divided into two groups. Group A had uninterrupted insurancecoverage for the final 48 pre-treatment months and the first 48 post treatment months. Thestudy results showed that pre-treatment, treated alcoholics averaged $159 per month whilstuntreated alcoholics averaged $171. Following treatment, treated individuals’ costs averaged$228/month (including cost of alcohol treatment) whereas untreated alcoholics averaged $346per month. For a second group, who had 14 years of continuous enrolment in the insurancesystem, after controlling for group differences, the average monthly health care costs oftreated alcoholics were 24% lower than for untreated, with adjusted means of $162 and $201respectively. 11.20 Holder and Blose conclude that following alcohol treatment, health care costs fortreated alcoholics drop an estimated 23% to 55% below cost levels that exist immediatelyprior to treatment. However, the costs do not appear to drop until about six months aftertreatment due to the cost impacts of the alcohol treatment itself.
Age, gender and cost offsets 11.21 Blose and Holder (1991) conducted an analysis of age and sex effects based on thesame USA data set as the 1992 paper. No gender differences were found in health care costsafter treatment, with post treatment monthly averages almost identical: $143 for men and$141 for women. However, health care cost reductions after treatment were found in theyounger age groups (under 30 years and 31-50 years) whilst those aged over 50 experiencedincreasing costs. The under 30 age group experienced an average reduction of $34 a monthfollowing treatment, and the 31-50 group experienced a reduction of $59 a month. Thoseaged 51 and over experienced a sizeable increase of $133 per month. 11.22 Holder and Blose's cost-offset studies illustrate that cost-offset effects are evident inUS insurance data, but the effects may not be experienced equally by all groups. Relevance to the UK 11.23 Unfortunately, since the majority of studies are based in the USA, the applicability tothe UK is very limited. Firstly, the health care system in the USA is non-comparable, basedheavily on an insurance system. The medical records of insurance companies and self-insured employers provide data sets with which to investigate the cost-offset hypothesis.However, the incentives to use care and price faced by the user of care are dependent upon thetype of insurance system, which is not comparable with the UK NHS. Secondly, the hospitalbilling systems used to compute treatment costs also limit generalisability to the UK sincecosts in such a system are unlikely to apply to the UK health care system. Thirdly, the clientpopulation in the USA and the range of alcohol problems and sociological factorssurrounding the use of alcohol are not the same as in the UK, together with a background ofdifferent legislation and licensing of alcohol products.
130
Tab
le11
.3Su
mm
ary
of E
ffec
tive
ness
Stu
dies
Rev
iew
ed o
n O
ther
Iss
ues
Aut
hor(
s) a
nd D
ate
Sear
chSt
rate
gy In
clus
ion
/E
xclu
sion
Cri
teri
a Q
ualit
yas
sess
ed N
umbe
r of
stud
ies
Tar
get
Gro
up M
ain
Find
ings
Art
hur
D A
lcoh
ol-
rela
ted
prob
lem
s: a
crit
ical
rev
iew
of
the
liter
atur
e an
ddi
rect
ions
in n
urse
educ
atio
n 19
98 N
urse
Edu
cati
on T
oday
18:4
77-4
87
Not
rep
orte
d N
ot r
epor
ted
Not
repo
rted
5 su
rvey
s of
nurs
eed
ucat
ion.
Nur
ses
Thi
s re
view
was
con
cern
ed w
ith
the
cont
ent o
f nu
rse
educ
atio
n, in
the
cont
ext o
f th
e po
tent
ial r
ole
of n
urse
s in
inte
rven
ing
with
prob
lem
dri
nker
s. T
here
wer
e fe
w s
tudi
es a
nd th
ese
indi
cate
dre
lativ
ely
few
hou
rs d
evot
ed to
alc
ohol
. L
ittle
atte
ntio
n w
as g
iven
to a
sses
smen
t and
clin
ical
ski
lls in
this
are
a. T
here
is m
ore
relia
nce
on s
peci
alis
ed p
ost-
regi
stra
tion
cour
ses.
Col
anto
nio
AA
sses
sing
the
effe
cts
ofem
ploy
ee a
ssis
tanc
epr
ogra
mm
es :
a re
view
of e
mpl
oyee
ass
ista
nce
prog
ram
eva
luat
ions
1989
The
Yal
eJo
urna
l of
Bio
logy
and
Med
icin
e 62
: 13
-22
Yes
Exc
lude
d ab
stra
cts,
unpu
blis
hed
man
uscr
ipts
,co
mpa
ny r
epor
tsan
d pu
blic
atio
ns in
non-
peer
rev
iew
edjo
urna
ls.
Not
repo
rted
13 E
mpl
oyee
s T
he m
ost f
requ
ently
use
d in
terv
entio
n w
as c
ouns
ellin
g (7
0% o
fst
udie
s).
The
pro
vide
r w
as n
ot a
lway
s sp
ecif
ied
but i
n 15
% o
fst
udie
s it
was
a tr
aine
d nu
rse.
Stu
dies
wer
e fr
om th
e U
S an
dC
anad
a. T
he in
terv
enti
on to
ok p
lace
out
wit
h th
e w
orkp
lace
in a
tle
ast 3
9% o
f st
udie
s. A
ll th
e pr
ogra
ms
repo
rted
pos
itive
res
ults
but
the
auth
or o
f th
e re
view
doe
s no
t sup
port
thes
e fi
ndin
gs g
iven
the
wea
knes
ses
of th
e st
udie
s. O
utco
mes
wer
e m
easu
red
in te
rms
ofw
ork
rela
ted
issu
es, s
uch
as r
educ
tion
s in
wor
k ti
me
lost
, acc
iden
tsan
d di
scip
linar
y ac
tions
, as
wel
l as
drin
king
beh
avio
ur.
Egg
R e
t al.
Eva
luat
ions
of
corr
ectio
nal t
reat
men
tpr
ogra
ms
in G
erm
any:
A r
evie
w a
nd m
eta-
anal
ysis
. Sub
stan
ceU
se a
nd M
isus
e. 2
000;
35(1
2-14
): 1
967-
2009
.
Publ
ishe
dan
dun
publ
ishe
dre
port
s in
Eng
lish
and
Ger
man
from
196
8 to
1996
.
Incl
uded
trea
tmen
tsw
ithin
the
crim
inal
just
ice
syst
em.
Exc
lude
d: if
no
outc
ome
data
; on
lya
subj
ecti
veev
alua
tion;
pilo
tst
udie
s; n
o sa
mpl
esi
ze r
epor
ted;
no
repo
rt o
f ou
tcom
ean
alys
es c
ompa
ring
the
trea
tmen
t gro
upw
ith
a co
ntro
lgr
oup.
Yes
. 25
stu
dies
wer
ein
clud
ed.
Cri
min
alof
fend
ers
The
met
hod
ratin
g of
the
25
stud
ies
was
mai
nly
“fai
r” (
n=16
), o
r“p
oor”
(n=
7).
One
stu
dy w
as r
ated
“go
od”
and
one
“exc
elle
nt”.
The
odd
s ra
tio o
f al
l the
stu
dies
, (n=
8), i
nvol
ving
soc
ial t
hera
py w
as1.
903,
ind
icat
ing
that
on
aver
age,
the
odd
s of
a s
ucce
ssfu
l ou
tcom
ein
the
expe
rim
enta
l gro
up w
ere
alm
ost t
wic
e as
hig
h as
the
odds
of
asu
cces
sful
out
com
e in
the
con
trol
gro
up.
The
5 e
duca
tion
al a
ndvo
catio
nal
prog
ram
s w
ere
not
foun
d ef
fect
ive.
T
he
4 dr
iver
impr
ovem
ent
prog
ram
s w
ere
indi
cate
d to
be
som
ewha
t ef
fect
ive
(p=
0.03
1).
The
evi
denc
e fr
om th
is m
eta-
anal
ysis
sup
port
s th
e hy
poth
esis
edef
fect
iven
ess
of th
e so
cial
ther
apy
prog
ram
s. E
duca
tion
al p
rogr
ams
did
not s
eem
to h
ave
an im
pact
. D
rivi
ng u
nder
the
infl
uenc
epr
ogra
ms
wer
e no
t sta
tist
ical
ly s
igni
fica
nt, b
ut p
rom
isin
g ac
cord
ing
to th
e au
thor
s.
131
Fing
erho
od M
.Su
bsta
nce
abus
e in
olde
r pe
ople
. Jou
rnal
of th
e A
mer
ican
Ger
iatr
ics
Soci
ety.
2000
; 48(
8): 9
85-9
5.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
Not
rep
orte
d E
lder
ly (
over
65 y
ears
) Su
bsta
nce
abus
e is
com
mon
in o
lder
peo
ple.
Old
er a
dult
s ar
epa
rtic
ular
ly s
usce
ptib
le to
adv
erse
med
ical
out
com
es f
rom
subs
tanc
e ab
use,
and
rec
ent s
tudi
es s
how
that
bri
ef in
terv
enti
ons
bypr
imar
y ca
re p
rovi
ders
can
hav
e a
maj
or im
pact
on
prev
enti
ngm
edic
al m
orbi
dity
and
impr
ovin
g qu
ality
of
life.
Tre
atm
ent
mod
aliti
es f
or s
ubst
ance
abu
se in
old
er p
eopl
e sh
ould
be
indi
vidu
alis
ed to
opt
imis
e su
cces
s. G
ill J
Alc
ohol
prob
lem
s in
empl
oym
ent:
epid
emio
logy
and
resp
onse
s. A
lcoh
ol &
Alc
ohol
ism
199
4;29
(3)
233-
248
Not
rep
orte
d N
ot r
epor
ted
Not
repo
rted
Not
rep
orte
d W
orki
ng a
ge T
he r
evie
w c
over
s th
e co
st a
nd e
xten
t of
alco
hol-
rela
ted
prob
lem
sin
em
ploy
men
t and
the
effe
ctiv
enes
s of
str
ateg
ies
to p
reve
nt o
rre
duce
pro
blem
s. F
ew w
orkp
lace
init
iati
ves
have
bee
n ri
goro
usly
asse
ssed
and
mos
t of
the
liter
atur
e is
fro
m th
e U
S. T
here
is li
mite
dev
iden
ce s
ugge
stin
g th
at e
mpl
oyee
ass
ista
nce
prog
ram
mes
hav
ere
duce
d su
bseq
uent
hea
lth
care
cos
ts.
The
aut
hor
disc
usse
sdi
ffer
ence
s in
nat
iona
l res
pons
es to
alc
ohol
pro
blem
s in
the
wor
kpla
ce.
Jarv
is T
J. I
mpl
icat
ions
of g
ende
r fo
r al
coho
ltr
eatm
ent r
esea
rch:
Aqu
antit
ativ
e an
dqu
alita
tive
revi
ew.
Bri
tish
Jour
nal o
fA
ddct
ion
1992
; 87(
9):
1249
-61.
Not
repo
rted
. In
clud
ed s
tudi
esga
ve c
onsu
mpt
ion-
rela
ted
trea
tmen
tou
tcom
e da
ta f
orm
en a
nd w
omen
and
the
appr
opri
ate
info
rmat
ion
for
the
calc
ulat
ion
of a
nef
fect
siz
e w
aspr
ovid
ed.
Wom
en
Sex
diff
eren
ces
betw
een
men
and
wom
en in
alc
ohol
trea
tmen
tou
tcom
e ar
e sm
all.
Wom
en a
ppea
r to
hav
e be
tter
resu
lts in
the
firs
tye
ar o
f fo
llow
-up,
whi
le m
en h
ave
bette
r re
sults
aft
er 1
2 m
onth
sfo
llow
-up.
The
est
imat
ed d
iffe
renc
es w
ere
smal
l and
der
ived
fro
ma
hete
roge
neou
s sa
mpl
e of
stu
dies
. E
vide
nce
from
the
stud
ies
in th
em
eta-
anal
ysis
is u
sed
to h
ighl
ight
the
impo
rtan
ce o
f ge
nder
-rel
ated
fact
ors
whi
ch m
ay im
pact
on
the
proc
ess
and
outc
omes
of
trea
tmen
t. I
n pa
rtic
ular
, sex
dif
fere
nces
in p
hysi
olog
ical
res
pons
esto
alc
ohol
, in
soci
al n
orm
s fo
r al
coho
l, an
d in
soc
io-c
ultu
ral
expe
rien
ces
are
cons
ider
ed im
port
ant a
reas
for
fut
ure
inve
stig
atio
nin
alc
ohol
trea
tmen
t res
earc
h K
urtz
NR
et a
l.M
easu
ring
the
succ
ess
of o
ccup
atio
nal
alco
holi
sm p
rogr
ams.
Jour
nal o
f St
udie
s on
Alc
ohol
. 198
4;45
(1):
33-4
5.
Not
rep
orte
d In
clud
ed: s
tudi
esw
ith s
ampl
e si
zes
ofN
>50
; stu
dies
of
spec
ific
OA
Ps.
Exc
lude
d:ev
alua
tion
s th
atm
erel
y ha
dem
ploy
ed p
erso
nsam
ong
thei
r ot
her
patie
nts.
Yes
. 9
stud
ies
used
cha
nge
in d
rink
ing
beha
viou
r;16
stu
dies
used
wor
kpe
rfor
man
ce;
and
11 u
sed
cost
redu
ctio
nas
outc
omes
.
Not
repo
rted
. T
here
are
a n
umbe
r of
obs
tacl
es t
o m
easu
ring
out
com
e su
cces
sin
clud
ing
poor
do
cum
enta
tion
by
em
ploy
ers,
la
ck
of
acce
ss
tosu
bjec
ts a
nd r
eluc
tanc
e on
the
par
t of
em
ploy
ers
and
trea
tmen
t st
aff
to a
llow
stu
dies
. T
he m
ajor
ity
of r
esea
rch
revi
ewed
was
con
duct
ed b
y in
dige
nous
prog
ram
sta
ff.
The
abs
ence
of
prof
essi
onal
res
earc
hers
is
perh
aps
mor
e pr
omin
ent
in O
AP
s th
an i
n an
y ot
her
trea
tmen
t co
ntex
t. T
heso
lutio
n re
sts
not
only
in
indu
cing
mor
e qu
alif
ied
rese
arch
ers
to t
hefi
eld,
but
in
indu
cing
tre
atm
ent
staf
f an
d co
rpor
ate
offi
cial
s to
be
mor
e ac
cept
ing
of th
e im
port
ance
of
prof
essi
onal
res
earc
h.
132
McA
voy
BR
Alc
ohol
educ
atio
n fo
r ge
nera
lpr
actit
ione
rs in
the
Uni
ted
Kin
gdom
– a
win
dow
of
oppo
rtun
ity?
200
0A
lcoh
ol a
ndA
lcoh
olis
m 3
5(3)
:22
5-22
9
Yes
Not
rep
orte
d N
otre
port
ed 5
surv
eys
Doc
tors
The
re is
no
stan
dard
ised
UK
sys
tem
for
the
educ
atio
n an
d tr
aini
ngof
GP
s in
rel
atio
n to
the
prev
entio
n, e
arly
det
ectio
n an
dm
anag
emen
t of
alco
hol p
robl
ems.
A m
ore
syst
emat
ic a
ppro
ach
inA
ustr
alia
and
the
US
has
incr
ease
d al
coho
l-re
late
d te
achi
ng h
ours
.H
owev
er, t
here
is a
lack
of
evid
ence
dem
onst
rati
ng im
pact
on
med
ical
beh
avio
urs
or e
valu
atin
g th
e co
st-e
ffec
tive
ness
of
diff
eren
ted
ucat
iona
l str
ateg
ies.
McM
urra
n M
Alc
ohol
inte
rven
tions
inpr
ison
s: to
war
dsgu
idin
g pr
inci
ples
for
effe
ctiv
e in
terv
entio
n19
95 P
sych
olog
y,C
rim
e an
d L
aw 1
: 215
-26
Not
rep
orte
d N
ot r
epor
ted
Not
repo
rted
Not
rep
orte
d Pr
ison
ers
Thi
s pa
per
revi
ews
evid
ence
rel
atin
g to
cor
rect
iona
l tre
atm
ent a
ndid
entif
ies
impl
icat
ions
for
inte
rven
tion
prog
ram
mes
in p
riso
ns.
Inge
nera
l int
erve
ntio
ns c
ondu
cted
in in
stitu
tions
hav
e le
ss im
pact
than
inte
rven
tions
in th
e co
mm
unity
. C
lient
cha
ract
eris
tics
whi
ch a
reas
soci
ated
with
poo
r tr
eatm
ent o
utco
mes
are
pre
cise
ly th
ose
whi
char
e pr
omin
ent i
n of
fend
er g
roup
s an
d th
ese
shou
ld b
e ad
dres
sed
inth
e in
terv
entio
n. S
truc
ture
d co
gniti
ve-b
ehav
iour
al p
rogr
amm
es a
rese
en to
be
mos
t eff
ecti
ve.
How
ever
, a s
urve
y of
inte
rven
tion
s in
UK
pri
sons
sug
gest
s th
at e
duca
tiona
l int
erve
ntio
ns s
till p
lay
apr
omin
ent r
ole.
Bri
ef in
terv
entio
ns c
an a
lso
be e
ffec
tive
with
prob
lem
dri
nker
s. D
rink
ing
goal
s of
mod
erat
ion
or a
bstin
ence
shou
ld b
e m
atch
ed to
clie
nt c
hara
cter
istic
s. W
orki
ng in
gro
ups
can
be p
robl
emat
ic.
Roc
he A
M A
lcoh
olan
d dr
ug e
duca
tion
and
trai
ning
: a r
evie
w o
fke
y is
sues
199
8D
rugs
: edu
catio
n,pr
even
tion
and
pol
icy
5(1)
: 85-
99
Not
rep
orte
d N
ot r
epor
ted
Not
repo
rted
Not
rep
orte
d Pr
ofes
sion
als
and
volu
ntee
rs
Thi
s pa
per
revi
ews
a ra
nge
of is
sues
rel
atin
g to
edu
catio
n an
dtr
aini
ng, i
nclu
ding
who
to tr
ain
and
the
cont
ent o
f tr
aini
ng.
In o
rder
to m
axim
ise
pote
ntia
l for
pre
vent
ion
and
man
agem
ent o
f al
coho
lan
d dr
ug r
elat
ed p
robl
ems,
edu
catio
n an
d tr
aini
ng f
or g
ener
alis
tw
orke
rs is
as
impo
rtan
t as
that
pro
vide
d fo
r sp
ecia
list
wor
kers
.E
duca
tion
and
trai
ning
pro
gram
mes
sho
uld
refl
ect t
he m
ulti-
disc
iplin
ary
natu
re o
f th
e fi
eld.
Mor
e ev
alua
tion
of tr
aini
ngpr
ogra
mm
es is
req
uire
d. R
oman
PM
and
Blu
mT
C A
lcoh
ol: a
rev
iew
if th
e im
pact
of
wor
ksite
inte
rven
tions
on h
ealt
h an
dbe
havi
oura
l out
com
es19
96 A
mer
ican
Yes
Des
crib
edel
sew
here
Yes
24 s
tudi
esin
clud
ed E
mpl
oyee
s 19
stu
dies
wer
e in
terv
entio
ns w
ith th
e w
orkf
orce
and
5 in
volv
eded
ucat
ion
and
trai
ning
for
man
ager
s an
d su
perv
isor
s. T
he o
vera
llqu
ality
of
the
stud
y de
sign
s w
as a
sses
sed
as w
eak,
with
onl
y 2
stud
ies
havi
ng p
rope
r ra
ndom
ised
con
trol
gro
ups.
Des
pite
thes
ew
eakn
esse
s, th
e ev
iden
ce te
nds
to s
uppo
rt in
terv
entio
ns b
ased
on
the
Em
ploy
ee A
ssis
tanc
e P
rogr
am m
odel
. T
rain
ing
and
educ
atio
nch
ange
s at
titud
es a
nd b
ehav
iour
and
incr
ease
s th
e us
e of
the
EA
P
133
Jour
nal o
f H
ealth
Pro
mot
ion;
11(
2); 1
36-
49
appr
oach
.
Sam
et J
H, F
ried
man
P,
Saitz
R. B
enef
its o
flin
king
pri
mar
ym
edic
al c
are
and
subs
tanc
e ab
use
serv
ices
: Pat
ient
,pr
ovid
er a
nd s
ocie
tal
pers
pect
ives
. Arc
hive
sof
Int
erna
l Med
icin
e20
01; 1
61 (
1): 8
5-91
.
Not
repo
rted
. N
ot r
epor
ted.
Not
repo
rted
Not
rep
orte
d N
otre
port
ed.
Prim
ary
care
is n
ot r
estr
icte
d to
phy
sici
ans,
but
rat
her
incl
udes
am
ultid
isci
plin
ary
team
. T
hus,
the
fact
that
pri
mar
y ca
re p
hysi
cian
sfe
el o
verb
urde
ned
shou
ld n
ot p
recl
ude
the
deve
lopm
ent o
f a
link
age
syst
em w
ith
subs
tanc
e ab
use
serv
ices
, but
rat
her
shou
ld in
flue
nce
its
deve
lopm
ent s
o th
at it
s im
plem
enta
tion
does
not
rel
y so
lely
on
phys
icia
ns.
The
abi
lity
to tr
eat s
ubst
ance
abu
se in
less
inte
nsiv
ese
tting
s w
ill p
rom
ote
cost
sav
ings
and
cos
t-ef
fect
iven
ess.
The
re is
rapi
d re
orga
nisa
tion
of
heal
th c
are
serv
ices
, and
des
pite
the
inhe
rent
diff
icul
ties
this
pre
sent
s, it
als
o pr
esen
ts th
e op
port
unit
y to
rest
ruct
ure
inad
equa
te s
yste
ms
of h
ealt
h ca
re d
eliv
ery.
Giv
en th
epo
tent
ial b
enef
its o
f cr
eatin
g ta
ngib
le s
yste
ms
in w
hich
pri
mar
yca
re, m
enta
l hea
lth,
and
sub
stan
ce a
buse
ser
vice
s ar
e m
eani
ngfu
lly
link
ed, e
ffor
ts to
impl
emen
t, ex
amin
e, a
nd m
easu
re th
e re
al im
pact
shou
ld b
e a
high
pri
ority
Sobe
ll L
C e
t al
Nat
ural
rec
over
y fr
omal
coho
l and
dru
gpr
oble
ms:
met
hodo
logi
cal r
evie
wof
the
rese
arch
wit
hsu
gges
tions
for
fut
ure
dire
ctio
ns.
2000
Add
ictio
n 95
(5):
749
-76
4
Yes
Incl
uded
stu
dies
inE
nglis
h, in
pee
rre
view
ed jo
urna
lsor
pre
sent
ed a
tpr
ofes
sion
alco
nfer
ence
. St
udie
sha
d or
igin
al r
esul
tsfo
r re
spon
dent
sw
ith p
ast h
isto
ry o
fal
coho
l or
drug
prob
lem
s
Yes
38 s
tudi
esm
et th
ein
clus
ion
crit
eria
. 30
repo
rted
resu
lts f
oral
coho
l.
Rec
over
edad
dict
s an
dpr
oble
mdr
inke
rs.
Thi
s re
view
cov
ers
the
char
acte
rist
ics
of s
elf
reco
very
pop
ulat
ions
.M
ost s
tudi
es p
rovi
ded
inco
mpl
ete
deta
ils.
Rea
sons
for
rec
over
y,fa
ctor
s he
lpin
g to
mai
ntai
n ab
stin
ence
and
bar
rier
s to
see
king
trea
tmen
t are
rep
orte
d. M
ost s
tudi
es h
ad w
eak
met
hodo
logi
es.
134
Tab
le11
.4Su
mm
ary
of C
ost-
Eff
ecti
vene
ss S
tudi
es R
evie
wed
on
Oth
er I
ssue
s St
udy
Typ
e of
Ana
lysi
s Po
pula
tion
Inte
rven
tion
Out
com
es R
esul
ts
M
cKen
na e
t al.
The
SE
CC
AT
surv
ey I
: The
cost
s an
dco
nseq
uenc
es o
fal
coho
lism
.A
lcoh
ol a
ndA
lcoh
olis
m.
1996
; 31(
6):
565-
76 (
1996
)
Part
ial e
valu
atio
n E
ligib
le p
atie
nts
at th
eA
lcoh
ol P
robl
ems
Clin
icin
Edi
nbur
gh.
586
clie
nts,
75%
mal
e, m
ean
age
46.0
yrs.
76%
had
initi
aldi
agno
sis
of a
lcoh
olde
pend
ence
, 21%
of
alco
hol a
buse
Var
ious
trea
tmen
ts a
t the
APC
.In
patie
nt a
nd o
utpa
tient
trea
tmen
t, ra
ngin
g fr
om in
tens
ive
supp
ortiv
e th
erap
y w
ithin
divi
dual
cou
nsel
ling
tode
toxi
fica
tion
with
gro
upth
erap
y. A
lso
disu
lfir
am th
erap
yan
d an
ti-de
pres
sant
s an
dre
com
men
datio
n to
mak
e co
ntac
tw
ith
othe
r ag
enci
es
SF36
, abs
tinen
t day
s.D
ays
off
wor
k, le
gal
even
ts
Cos
ts a
nd e
ffec
ts n
ot c
ombi
ned
as s
uch.
The
aut
hors
div
ide
the
resu
lts in
to q
uart
iles
and
show
that
the
mos
t abs
tinen
t gro
upm
ade
less
use
of
emer
genc
y ca
re.
For
the
othe
r gr
oups
res
ults
are
am
bigu
ous
show
ing
the
mid
dle
quar
tiles
usi
ng m
ore
reso
urce
s th
an th
e m
ost a
nd le
ast a
bsti
nent
.M
ean
heal
th c
are
cost
s w
ere
£113
4, o
fw
hich
38%
wer
e re
late
d to
APC
trea
tmen
t.M
ean
tota
l hea
lth s
ervi
ce c
osts
are
qua
rtile
1=£7
83, q
uart
ile 2
=£1
443,
qua
rtile
3=£1
446
and
quar
tile
4=£8
62.
For
APC
cost
s, th
ose
com
plet
ely
abst
inen
t or
not a
tal
l abs
tinen
t ove
r th
e 6
mon
th p
erio
d sh
owth
e lo
wes
t cos
ts.
Reg
ress
ions
sho
wed
age
was
neg
ativ
ely
rela
ted
to a
vera
ge to
tal c
ost
but t
he e
xpla
nato
ry p
ower
of
regr
essi
ons
wer
e lo
w.
Alc
ohol
dep
ende
nt p
atie
nts
wer
e sh
own
to h
ave
a gr
eate
r us
e of
hea
lthse
rvic
e re
sour
ces
than
alc
ohol
abu
sers
.H
igh
rate
s of
abs
ence
fro
m w
ork
and
acci
dent
s an
d le
gal c
onta
cts
wer
e re
cord
edbu
t the
se a
re n
ot c
oste
d. O
ver
20%
had
had
an a
ccid
ent a
t hom
e co
mpa
red
to 2
-4%
from
GH
S da
ta a
s a
popu
latio
n no
rm.
135
Tab
le 1
1.5
CO
ST O
FF
SET
EST
IMA
TE
S St
udy
Dat
a Po
pula
tion
Res
ults
Hol
der
HD
, Blo
se J
O.
The
red
uctio
n of
heal
th c
are
cost
sas
soci
ated
with
alco
holi
sm tr
eatm
ent:
A 1
4 ye
arlo
ngitu
dina
l stu
dy.
Jour
nal o
f St
udie
s on
Alc
ohol
. 199
2; 5
3(4)
:29
3-30
2.
Insu
ranc
e 37
29 a
lcoh
olic
s -
clai
min
g fo
ral
coho
l tre
atm
ent a
t a la
rge
mid
-Wes
tern
man
ufac
turi
ngco
mpa
ny
The
stu
dy r
esul
ts s
how
ed th
at p
re-t
reat
men
t, tr
eate
d al
coho
lics
aver
aged
$15
9 pe
r m
onth
whi
lst
untr
eate
d al
coho
lics
aver
aged
$17
1. F
ollo
win
g tr
eatm
ent,
trea
ted
indi
vidu
als
cost
s av
erag
ed$2
28/m
onth
(in
clud
ing
cost
of
alco
hol t
reat
men
t) w
here
as u
ntre
ated
alc
ohol
ics
aver
aged
$34
6 pe
rm
onth
. F
or a
sec
ond
grou
p, w
ho h
ad 1
4 ye
ars
of c
onti
nuou
s en
rolm
ent i
n th
e in
sura
nce
syst
em,
afte
r co
ntro
llin
g fo
r gr
oup
diff
eren
ces,
the
aver
age
mon
thly
hea
lth
care
cos
ts o
f tr
eate
d al
coho
lics
wer
e 24
% lo
wer
than
for
unt
reat
ed, w
ith a
djus
ted
mea
ns o
f $1
62 a
nd $
201
resp
ectiv
ely)
.
Blo
se, J
O &
Hol
der,
HD
The
util
isat
ion
ofm
edic
al c
are
bytr
eate
d al
coho
lics
:L
ongi
tudi
nal p
atte
rns
by a
ge, g
ende
r, a
ndty
pe o
f ca
re, 1
991
Jour
nal o
f Su
bsta
nce
Abu
se, 3
, 13-
27.
Insu
ranc
e 22
59 tr
eate
d al
coho
lics
at a
larg
e m
id-W
este
rnm
anuf
actu
ring
com
pany
No
gend
er d
iffe
renc
es in
hea
lth
care
cos
ts a
fter
trea
tmen
t, w
ith
post
trea
tmen
t mon
thly
ave
rage
s:$1
43 f
or m
en a
nd $
141
for
wom
en.
Hea
lth c
are
cost
red
uctio
ns a
fter
trea
tmen
t fou
nd in
the
youn
ger
age
grou
ps (
unde
r 30
yea
rs a
nd 3
1-50
yea
rs)
whi
lst t
hose
age
d ov
er 5
0 ex
peri
ence
din
crea
sing
cos
ts. U
nder
30
age
grou
p ex
peri
ence
d av
erag
e re
duct
ion
of $
34 a
mon
th f
ollo
win
gtr
eatm
ent;
31-5
0 gr
oup
expe
rien
ced
a re
duct
ion
of $
59 a
mon
th.
Tho
se a
ged
51 a
nd o
ver
expe
rien
ced
a si
zeab
le in
crea
se o
f $1
33 p
er m
onth
.
136
CHAPTER TWELVE EVALUATING INTERVENTIONS IN SCOTLAND
SUMMARY This chapter considers some of the interventions that have been implemented and evaluated inScotland. Information is provided on:• the range and type of services evaluated in Scotland;• the quality and robustness of the evaluation work carried out;• key components that future evaluation work should encompass; and• improvements that can be made in the accessibility of unpublished reports.
INTRODUCTION 12.1 The purpose of this chapter is to describe some of the interventions being carried out inScotland and the extent to which they have or have not been evaluated. These examples will beused to draw lessons about improvements in the evaluation framework and the process ofknowledge management. The topic coverage is representative rather than comprehensive.
EVALUATIONS IN SCOTLAND 12.2 As a parallel exercise to the main literature review, health promotion specialists and localalcohol advisory committees were contacted in an effort to identify interventions taking place inScotland that had been evaluated. Eight organisations provided positive responses, someincluding more than one initiative. The types of intervention reported were:
• Designated Driver Scheme• Befriending Services• GP Alcohol Counselling Services• Provision of Complementary Therapy• Rough Sleepers Initiative/Counselling for Young Women• Home detoxification services• Young Scot Card• Community School initiative
12.3 Other interventions in Scotland that were known about included server interventionprogrammes, nurse based minimal intervention initiatives, designated places and the teenwisealcohol project (TAP). A further limited search was undertaken to try to identify other researchreports, published or unpublished, relating to such interventions. Some examples of theevaluations undertaken follow and these cover most of the categories of intervention reported inprevious chapters, although it is notable that no examples of policy evaluations were identified.Treatment studies, such as drug trials, have not been included as these are well covered by the
137
effectiveness reviews and there are not thought to be distinctive messages from Scottish basedstudies.
Enforcement
Designated Driver Scheme
12.4 Dumfries and Galloway introduced a designated driver scheme, starting with a pilot in1992 (Cawte 1995). The primary aim was to evaluate the viability of the scheme, in which adesignated driver with 2 or more passengers would receive free soft drinks in participatinglicensed premises. The pilot scheme involved 19 licensees and over 160 drivers took part. Forthe main scheme, 156 licensed premises stratified by category and selected at random wereapproached. 64 premises agreed to participate. The evaluation concentrated on reactions fromlicensees, awareness of the scheme amongst customers and attitudes of customers towardsdrinking and drink driving. Information was collected through questionnaires and interviews. Inaddition, licensees were asked to record the number of free drinks provided each month andunannounced visits were made to observe the use of the scheme in participating premises. Anumber of recommendations were made including the need for incentives for licensees, who borethe cost of the free drinks, and for the promotion of such schemes in the future.
Teenwise Alcohol Projects
12.5 The Teenwise Alcohol Projects (TAP) were a series of police led, community basedinitiatives to tackle under-age drinking (Anderson and Sawyer 1999). The evaluation wasconcerned with the implementation and impact of the campaign. Views were sought from youngpeople, their parents, the police and staff in the licensed trade and the focus of the researchincluded the nature of the problem as well as responses to the problem. Questionnaires andinterviews were used with young people to obtain information on drinking behaviour. Whilstthere was general support for interventions on under-age drinking from parents and licensees,young people thought that they should be left alone if they were not causing trouble. There wasperceived to be a reduction in public drinking by young people but it was unclear whether thiscould be attributed to the TAP intervention. Both local bye-laws and national legislation cameinto effect at the same time. The evaluation was not designed to identify whether under-agedrinking had reduced or had been displaced to other locations.
Prevention
Alcohol education initiatives
12.6 A review of alcohol education initiatives in Scotland was published in 1996 (Bagnall andFossey 1996). The report included discussion of:
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• school-based initiatives, using materials developed by the Scottish Health Education Groupand the Health Education Board Scotland, with some exploratory work on delivery methods;
• workplace initiatives by the Scottish Council on Alcohol and the development of alcoholpolicies for the workplace, training schemes and an awards scheme sponsored by drinksindustry;
• the Grampian Server Training Initiative started in 1992 (Server Intervention PreventionStrategy SIPS) targeting bar staff and providing training on licensing issues and good servicepractice;
• community interventions such as designated driver schemes and Drinkwise campaigns; and
• primary care interventions, such as training for GPs to provide skills to interveneopportunistically (Drinking Reasonably and Moderately with Self-control DRAMS).
12.7 The review was not specifically intended to consider effectiveness evidence, althoughevaluation is discussed. The authors draw attention to published systematic reviews in the area,which are dominated by US literature because few UK studies meet the inclusion criteria ondesign and evaluation. Although the need to incorporate evaluation into the design andimplementation of alcohol education initiatives was increasingly recognised, this was generally asecondary concern. The resulting evaluations were often short term, as was the funding of theinitiative itself. The need for more rigorous evaluation studies to be funded, with longer follow-up periods and at least quasi-experimental designs, was emphasised.
Brief interventions Health visitor scheme 12.8 This brief intervention was undertaken as part of a programme of innovative alcoholservices with evaluation funded by the Chief Scientist Office. Health visitors were trained andthen supported in screening women in their existing caseload, who had agreed to participate inthe study, and in delivering a minimal intervention to those drinking more than 14 units per week(Scott 2000). Screening was by means of a 7 day drinking diary and 13% of the sample of 430were found to be drinking above the recommended level. Outcomes were measured by 7 daydrinking diaries at 6 months following the intervention. At this point, 92% of the sample werefound to have reduced their weekly alcohol consumption. Those still drinking above therecommended level could receive up to two further interventions. 12.9 As evidence already existed about the effectiveness of brief interventions, the issue raisedin this study was the success of health visitors in undertaking the intervention. The interventionundoubtedly had an effect with the women recruited and the intervention process is welldescribed. The high success rates, which are greater than those generally reported in theliterature, may be partly explained by the probable exclusion of women who were uninterested orunwilling to participate. Also, part of the effect may be achieved by simply asking about
139
drinking behaviour without any intervention. This would be consistent with findings fromcontrolled studies. Counselling services 12.10 Two areas in Scotland report having evaluated counselling services provided by voluntaryorganisations working in primary care settings. The service in Forth Valley began in 1997 andwas evaluated in its third year of operation (Martinus et al 2001). 349 people had been referredto the service and 81% had kept their initial appointment. Reported drinking fell from a weeklyaverage of 112 units to 19 units by the fourth week of counselling. 12.11 The average number of sessions per patient was 10 (Martinus et al 2000a) and theestimated cost per patient was £420. This number of sessions indicates that the interventionwould be classed as more than a brief intervention. Although drinking levels were recorded,alcohol dependency was not assessed. Therefore, it is not possible to judge whether the studysubjects were unsuitable for a less intensive intervention. 12.12 A similar service was set up in 1995 in Fife and was evaluated in 1997 (Fife AlcoholAdvisory Service). Over 11 months, a total of 257 patients were offered counselling in one of 9health centres and the take up was 81%. The average alcohol consumption of patients startingcounselling was 142 units per week. The service was in the process of developing its records andinformation from a 1st progress review was available for 62 patients; their reported alcoholconsumption fell from 129 units per week at assessment to 19 units per week. 12.13 The objectives of the Fife service were stated in terms such as providing better access toalcohol services, widening the range of services and improving the working together of thevoluntary sector and primary care. The evaluation that took place was directed at these issues(Centre for Health and Social Research). Interviews with primary health care staff andcounsellors found considerable support for the counselling service but suggested that furtherefforts were required in terms of service integration. Complementary therapy 12.14 The provision of complementary therapies (CT) as an adjunct to counselling wasintroduced in Clydebank in 1997. Participants had chosen to receive CT and may have beenbetter motivated than the non CT control group. However, comparisons were also possiblebetween those who received CT and those placed on a waiting list because of excess demand(McMahon 1998). The numbers available for analysis were small (25 received CT, 18 on thewaiting list WCT, and 14 declined NCT). The CT group did achieve the greatest reduction inweekly alcohol consumption at 6 weeks but the difference was not statistically significant whencompared with the NCT group, probably because of the small numbers. Interestingly, the WCTgroup did less well than either the CT or NCT groups. The results for the WCT did improvewhen reassessed after receiving CT but not by very much. This suggests that the timing ofproviding CT may be important.
140
12.15 In Forth Valley, the Complementary Therapies Project provided access to a range ofcomplementary therapies for people already receiving treatment for substance misuse from eitherthe Central Scotland Council on Alcohol or the Community Alcohol and Drugs Service(Martinus et al 2000b). The numbers available for evaluation were very small and results are notspecific for individual therapies. Only qualitative effects on drug and alcohol use are reported.
Detoxification Home detoxification 12.16 A home-based detoxification service was introduced in Ayrshire and Arran in 1995 tooffer an alternative approach for suitable patients (Stark et al 1999a). The service would not beoffered if home circumstances were unsuitable or if there were medical contraindications.Referrals in the first year were 747, of which 559 were for alcohol. Of the alcohol cases, 57%completed detoxification and follow-up. Substance use at discharge showed 13% with controlleduse of alcohol and 57% abstinent. 12.17 There was no control group but a no treatment group would not be feasible in studies ofdetoxification. The outcomes could have been compared with inpatient treatment but patientcharacteristics would differ. The accepted spontaneous remission rate in the literature is onethird and this service achieved rates which were double this for patients who accepted treatment.No longer term follow-up was reported. 12.18 Other areas have also reported providing home detoxification services. The first suchservice was established in 1991 to relieve demands on inpatient facilities (Bennie 1998). Acomparison was carried out between the home detoxification service and a minimal interventiontreatment strategy, with random allocation of referrals. At 6 months both groups showed someimprovement with respect to drinking behaviour, alcohol related problems and use of otherservices. Patients in the home detoxification group remained abstinent twice as long aftertreatment as those in the minimal intervention group. Another study has shown both homedetoxification and day hospital treatment to be viable alternatives to inpatient treatment Allan etal 2000). Home detoxification is often suggested as a more suitable service for meeting theneeds of women but no difference in the gender mix between inpatient and home based serviceshas been found (Madden et al 2000).
CRITICAL APPRAISAL 12.19 What emerges very clearly from the studies described above is that the simple term‘evaluation’ has a host of meanings. The aims of the evaluations carried out were very disparateand they were not primarily concerned with the effectiveness of the services in most cases.Those reports that did address the issue of effectiveness were necessarily limited by smallnumbers and the adequacy of controls. Nevertheless, these studies mainly had a clear objectiveand an appropriate research design. They could provide useful information for service planningwhere effectiveness has been confirmed by peer-reviewed research evidence. In some cases, the
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content of the service being provided may need to be compared with that of the interventionevaluated in the literature. 12.20 Some of the evaluations had less clearly focussed objectives and could be improved by aclearer statement of the underlying hypothesis. Other common problems include the lack ofcomparison groups, the need for longer follow up periods and independent confirmation ofdrinking status. These issues are recognised by some of the authors and research designs arefrequently constrained by what is possible. The same criticisms can be levelled at much of thewider literature. Well-conducted qualitative research has a role to play in exploring underlyingissues and developing innovative services and this also requires a robust design.
EVALUATION GUIDELINES 12.21 Essential elements of evaluation do vary with the purpose of the evaluation. Hereattention is concentrated on two types. Evaluation to find out if an intervention works andevaluation of the local implementation of an intervention that has been shown to be effective inother studies. Some basic principles are addressed but more detailed evaluation guidelines havebeen developed by other bodies (Health Education Board for Scotland (Evaluation Toolkit) andScottish Executive Effective Interventions Unit). 12.22 Effectiveness evaluations require:• a clear definition of the aims and objectives of the intervention;• an appropriate outcome and how it is to be measured;• a control or comparison group is required with a robust research design to eliminate bias in
the results. Randomisation is the gold standard but reliable results can be obtained fromwell-conducted before and after or case-control studies; and
• sufficient numbers for statistically valid results and a longer term follow up. The last point is possibly the most difficult to achieve and it would be better for effectivenessevaluations to be concentrated on a smaller number of studies of adequate size and duration. Theneed to include independent measures of outcome, where possible, also has implications for theresources required for evaluations. Sample sizes need to be calculated with respect to thedifference between groups that is to be detected. Considering issues of cost-effectiveness canincrease the value of evaluations or at least providing details of the resources employed in theintervention. 12.23 When a service is implementing an intervention shown to be effective in the literature,the main purpose of the evaluation is to ensure that the results achieved elsewhere aretransferred. Such evaluations should;• document any differences in the local implementation of the intervention or in the
intervention population;• measure or monitor outcomes against the benchmark provided by the literature; and• provide information on the resources employed in the intervention.
The benchmarking of outcomes may need to allow for fact that effectiveness rates are oftenbased on ‘volunteer’ populations and may not be directly applicable to general populations.
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ACCESSIBILITY OF FINDINGS
12.24 Research findings should be accessible if they are to be of value in shaping thedevelopment of services and avoiding duplication of effort. The examples discussed in thischapter have been obtained from a variety of sources, including personal contact with authors.They cover research conducted by or for government departments, health services, voluntaryorganisations and academic institutions. There is no comprehensive source of such researchreports, particularly those that are unpublished, and there will be further examples not uncoveredby the searches undertaken for this report. This situation could be improved by the developmentof a searchable Scottish database of research findings. The value of such a database would beenhanced if it were possible to assess the quality and generalisability of results.
CONCLUSIONS
12.25 There has been considerable activity in Scotland in implementing initiatives to reducealcohol misuse and its consequences. Not all of these have been subject to rigorous evaluationand where evaluation has been carried out the results are not always readily accessible. The mostuseful findings reported here relate to brief interventions by health visitors and homedetoxification services. Counselling services are clearly effective but research is required toestablish whether the current pattern of provision is more effective than a briefer intervention.The role of complementary therapy requires larger studies to be carried out. A culture ofevaluation that is focussed on outcomes needs to be fostered at all levels from policy making toservice delivery.
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CHAPTER THIRTEEN CONCLUSIONS AND RECOMMENDATIONS
INTRODUCTION
13.1 This report has reviewed evidence on the effectiveness and cost-effectiveness ofinterventions aimed at reducing alcohol misuse. This chapter is in three parts. The first partsummarises the main findings relating to each of the outputs requested in the specification, withparticular emphasis on the key conclusions that can be drawn from the available evidence. Thesecond part summarises the implementation issues that need to be considered and the third setsout recommendations for the future, both in terms of interventions that should be pursued and theactions required to improve the evidence base.
REVIEW CONCLUSIONS
Summary of available evidence
Effectiveness
13.2 The main findings relating to interventions that are supported by the evidence base aresummarised in table 13.1. In terms of the effectiveness review, there is a strong and relevantevidence base to show that:• the use of price increases, via taxation, and brief interventions will reduce the number of
problem drinkers;• effective screening tools to detect problem drinkers are available (CAGE and AUDIT);• detoxification services and relapse prevention, through appropriate psychosocial and
pharmacological treatments, are effective.
13.3 There is evidence that legislative interventions to reduce permitted blood alcohol levelsfor drivers, to raise the legal drinking age and to control outlet density have been effective butthis evidence relates mainly to the US. There is no certainty that the results would transfer to theUK, where there is a different cultural attitude towards alcohol. Evidence from the US andAustralia supports the effectiveness of random breath testing of drivers but similar argumentsmay apply. There is no clear evidence of effectiveness relating to prevention of alcohol misuse,mainly because of the weaknesses of the research carried out. Some effects on knowledge andattitudes have been found but none relating to drinking behaviour.
144
Cost-effectiveness
13.4 The cost-effectiveness review found evidence to support the cost-effectiveness of:• brief interventions;• home and outpatient detoxification;• outpatient treatment for relapse prevention; and• the use of acamprosate as an adjunct treatment in relapse prevention.
13.5 None of the costs were taken from UK settings but the results for brief interventions andfor acamprosate have been confirmed using UK cost data. In general, regardless of the countrysetting, home treatment and outpatient treatment are likely to be cost-effective alternatives toinpatient treatment provided that they are at least as effective. The only UK cost-effectivenessresult related to the relative cost-effectiveness of specialist workers in screening for alcoholmisuse in a general hospital setting. The cost-effectiveness of random breath testing and servertraining programmes depends upon the cost-offsets achieved, and these may be lower in the UKthan in the US settings in which these studies took place. One Australian study has shown thatthiamine supplementation of full strength beer is cost-effective in the prevention of Wernicke-Korsakoff syndrome.
General issues
13.6 Interventions that do not appear in table 13.1 are not necessarily ineffective but no strongevidence to support them has been found in the review. It should be noted that because theeffectiveness evidence has been taken from existing reviews, there may be individual studiesproviding evidence of effectiveness that have not been included here. The size and strength ofthe evidence base is very variable but it is apparent that interventions are required across allareas. The different types of intervention are not substitutes for each other but tackle differentaspects of the alcohol misuse problem. There is much less evidence about cost-effectivenessthan effectiveness.
13.7 No attempt has been made to rank the interventions and the data available would notpermit this to be carried out in a robust way. It may not be particularly helpful to rank theinterventions in any case, as they are not direct alternatives. One study that has attempted to rankinterventions in terms of effectiveness was discussed in chapter 11 and demonstrates some of theproblems (Miller et al; 1998). Whilst this approach provides a useful indicator of the balance ofevidence on effectiveness, the ranking is influenced by the number of studies carried out.
13.8 A more useful approach to ranking interventions would be based on cost-effectiveness.However, the data required to permit such a ranking are not available in the literature.Consistent, robust and comparable information on the costs and outcomes of all interventionswould be required. Even if this information were available, such a ranking would have to beinterpreted with care. There is an inherent danger with ‘league tables’ that they are taken tomean that resources should only be applied to the intervention that tops the list, whereas suchrankings are more useful as a guide to the investment of resources at the margin. That is, theymay indicate that more benefit can be obtained by reallocating some (but not necessarily all)resources from less beneficial uses to more beneficial uses. Given that the interventions
145
considered here are not direct substitutes, judgement still requires to be exercised in specificresource allocation decisions.
Measures which have been evaluated for effectiveness and cost-effectiveness
Effectiveness
13.9 This report has identified a large amount of research over a wide range of topics. Theresults have been presented in chapters 4-11 and a summary of the measures supported byevidence was presented above (para 13.8 - 13.). The extent and quality of the research variesbetween types of intervention. Treatment interventions have been subject to the most rigorousevaluations and the literature contains a number of meta-analyses of well-conducted randomisedcontrolled trials. There is a large volume of research in the area of prevention but the studydesigns and the resulting evidence are weak. Policy interventions and the effects of legislationand enforcement have been less well researched.
Cost-effectiveness
13.10 The volume of cost-effectiveness literature is much smaller and is strongest in the areasof brief interventions and relapse prevention. A weakness of this area is that most studies havenot been conducted alongside effectiveness studies but have modelled results based on valuesobtained from the literature. Few studies have addressed the health benefits of interventions withthe result that outcomes in terms of cost per life year are rarely produced in the literature.
Categorisation by type of intervention
13.11 The interventions have been categorised according to the ‘stage’ of drinkingbehaviour that they address:
• policy and legislation set the context within which drinking occurs and seek to regulate behaviour in order to reduce adverse outcomes (chapter 4);
• enforcement ensure compliance with the regulatory framework (chapter 5);• prevention education and health promotion to avoid problem drinking and
alcohol abuse (chapter 6);• screening and detection identify problem drinking and alcohol dependence (chapter 7);• brief interventions address problem drinkers who have not reached the stage of
alcohol dependence (chapter8);• detoxification treat withdrawal symptoms on stopping drinking (chapter 9); and• relapse prevention avoidance of return to problem drinking (chapter 10). Additional results have been presented in chapter 11 relating to the location of services, servicesfor particular population subgroups and requirements for education and training. Chapter 12 hasconsidered evaluations in Scotland.
146
Targeting at sub-groups in the population 13.12 Within each results chapter, consideration has been given to the availability of evidencerelating to particular population subgroups. With the exception of prevention, where themajority of research relates to children and young people, target populations tend to relate todrinking behaviour and associated problems rather than to demographic groups. Thus, forexample, legislation may target under-age drinkers or previous drink drivers. Brief interventionsare effective for problem drinkers but not for those dependent upon alcohol. They have also beenfound to be ineffective with pregnant women and this is thought to be because of the highabstinence rates in this group without any intervention. Studies that have specifically focussedon the needs of women and older people have been reviewed in chapter 11 and these highlightthe possible organisational issues that should be addressed for these groups, rather thansuggesting any differences in the impact of specific interventions.
Assessment of quality Effectiveness 13.13 The effectiveness evidence has been taken from existing reviews and consideration hasbeen given to the quality of the review process including whether or not the quality of theprimary studies was assessed. In some areas, such as policy and legislation, research designs arelimited by the nature of the intervention. In other cases, such as enforcement and prevention,insufficient attention has been paid to the research design and this has weakened the evidencebase. The topics having the greatest amount of good quality research are brief interventions andrelapse prevention. A considerable amount of research has been conducted in the US and inother countries. These results must always be interpreted with care, in order to assess theirrelevance to the UK. This issue has been addressed within each results chapter but it is worthemphasising that differences in culture, such as attitudes to under-age drinking, and in objectives,such as abstinence versus sensible drinking, may affect the results of research particularly in theareas of policy, legislation, enforcement and prevention. Cost-effectiveness 13.14 The economic studies have been assessed against established guidelines for the conductof economic evaluations. Few good quality economic evaluations have been undertaken andthose presented within the results chapters are open to criticism, as noted in the accompanyingdiscussion. The studies presented represent the current state of the art and can provide usefulinsights about the likely economic impact of interventions, provided that they are interpretedwith care. This is particularly true when translating results from other countries and other healthcare systems. Cost data from other countries with insurance-based systems may overstate boththe cost of the intervention and the savings that result from avoiding the future use of health careservices.
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Main gaps in the evidence base 13.15 The gaps in the evidence base have been reported within each of the main resultschapters. There is a particular lack of sound evidence, applicable to the UK, in the area of policy,legislation and enforcement. More attention requires to be given to evaluating alcohol initiativesin the UK and these evaluations should be planned at an early stage in the development of aninitiative. Despite a plethora of research, the evidence relating to prevention is weak and betterresearch designs are required. In screening and treatment, there is a sound basis of evidence for anumber of interventions but additional research would be beneficial. In all areas, there is a needfor better economic studies.
Lessons about methods of evaluation 13.16 The methods of evaluation that are used in assessing treatments are well established andprovide robust results when correctly applied to large enough samples. In some cases, thedeficiencies in the evaluation of other types of intervention arise from the failure to adopt asimilarly robust approach. For example, studies of preventive interventions in schools havefrequently failed to provide adequate controls. However, interventions in areas such as policyand legislation cannot always be addressed by applying the same model. Better methods ofpolicy evaluation are required to provide robust evidence where there is no access to randomcontrols and these need to be developed and applied in a UK context to provide relevantinformation.
IMPLEMENTATION ISSUES 13.17 This report has identified a number of interventions that have been demonstrated to beeffective and may be cost-effective. These results will have to be interpreted alongsideinformation about interventions that are already taking place. Both the impact whichinterventions will have upon strategic targets and the resources required to implementinterventions will depend upon the extent to which they have already been deployed. It shouldalso be noted that the effectiveness of these interventions has been demonstrated in researchsettings and requires to be confirmed in routine practice. Arrangements for auditing ormonitoring the effectiveness of interventions will need to be put in place. 13.18 A potentially useful framework for considering implementation issues is provided in arecent study. This has reviewed the evidence relating to alcohol misuse strategies that arepopulation based or target high-risk groups (Smart and Mann 2000). The number of studies issmall and they have modelled results using a range of assumptions. However, there is aconsistent finding that, for a given reduction in total alcohol consumption, the impact on alcohol-related problems is similar regardless of whether the change is achieved across the wholepopulation or concentrated in higher risk groups. The costs of different strategies do not appearto have been taken into account.
148
RECOMMENDATIONS
Plan for Action 13.19 On the basis of the evidence reviewed, the two interventions most likely to impact onpopulation targets for problem drinking are taxation and brief interventions. The potential size ofthe impact is uncertain. In the case of taxation, the effect depends upon the size of the priceelasticity of demand and estimates of this vary. For brief interventions, the effect depends uponthe extent to which such services are already being provided. It is recommended that the Planfor Action should support:
• the introduction of a brief intervention programme where this is not alreadyprovided; and
• the development of monitoring arrangements to assess the impact of theseinterventions at the national level.
13.20 At the level of the individual, effective treatment of withdrawal symptoms and relapseprevention programmes are also important. The limited economic evidence available suggeststhat alcohol treatments have cost-effectiveness ratios well below current UK benchmarks forefficiency and indeed some may be resource saving. It is recommended that the Plan forAction should support:
• improved access to treatment and relapse prevention; and• the use of cost-effective alternatives, such as home detoxification, where
appropriate.
Research Strategy 13.21 In common with many other areas of policy interest, the evidence base with regard toeffectiveness and cost-effectiveness is incomplete. What is required is not simply more researchbut a more focussed use of research capacity and more accessible results. It is recommendedthat the Plan for Action should support:
• the prioritisation of policy evaluation and prevention as the areas requiring mostdevelopment of the evidence base;
• better co-ordination of research effort with resources concentrated on fewer largerstudies with longer term follow up;
• better knowledge management in terms of access to relevant research results;• the fostering of an evaluation culture amongst those responsible for delivering
services, focussed on outcomes and the monitoring of effectiveness; and• guidelines for evaluation to assist in this process.
149
Tab
le 1
3.1
Sum
mar
y of
Fin
ding
s
Eff
ecti
vene
ss e
vide
nce
supp
orts
Cos
t-ef
fect
iven
ess
evid
ence
supp
orts
Com
men
ts
Pol
icy
and
legi
slat
ion
Pri
ce in
crea
ses
via
taxa
tion
Not
hing
ha
s be
en
form
ally
eval
uate
dL
ower
pe
rmit
ted
bloo
d al
coho
lle
vels
; ra
isin
g le
gal
age
for
drin
king
;lo
wer
out
let d
ensi
ty
Evi
denc
e no
t fro
m U
K
Enf
orce
men
tR
ando
m b
reat
h te
stin
g of
dri
vers
Ran
dom
bre
ath
test
ing
of d
rive
rsU
S st
udy
impl
ies
cost
dat
a m
ay n
ot a
pply
.Se
rver
trai
ning
pro
gram
me
US
stud
y im
plie
s co
st d
ata
may
not
app
ly.
Pre
vent
ion
No
conv
inci
ng
effe
cts
have
be
ende
mon
stra
ted
on d
rink
ing
beha
viou
r.E
vide
nce
of e
ffec
t on
kno
wle
dge
and
attit
udes
fro
mm
ass
med
ia c
ampa
igns
. W
eak
evid
ence
of
effe
ct o
nkn
owle
dge
from
sch
ool-
base
d in
terv
enti
ons.
Thi
amin
e su
pple
men
tatio
n of
fu
llst
reng
th b
eer
to p
reve
nt W
erni
cke-
Kor
sako
ff s
yndr
ome
Aus
tral
ian
stud
y
Scre
enin
g an
d de
tect
ion
CA
GE
and
AU
DIT
as
scre
enin
g to
ols
for
gene
ral p
opul
atio
nsU
se
of
spec
iali
st
wor
kers
fo
rsc
reen
ing
in
a ge
nera
l ho
spita
lse
tting
UK
stu
dy.
Nur
sing
sta
ff w
ere
less
cos
t-ef
fect
ive
but
may
be
used
mor
e fl
exib
ly.
Bri
ef in
terv
enti
ons
Bri
ef
inte
rven
tions
in
a
rang
e of
rese
arch
set
ting
sB
rief
inte
rven
tions
No
cost
dat
a fr
om U
K s
tudi
es i
mpl
ies
cost
-off
sets
may
not
be
high
.D
etox
ific
atio
nB
enzo
diaz
epin
es
as
firs
t ch
oice
ther
apy
Hom
e an
d ou
tpat
ient
det
oxif
icat
ion
Rel
apse
pre
vent
ion
Psy
chos
ocia
l int
erve
ntio
nsO
utpa
tient
trea
tmen
tN
altr
exon
e an
d A
cam
pros
ate
asad
junc
t tre
atm
ents
Aca
mpr
osat
e as
an
ad
junc
ttr
eatm
ent
Cos
t da
ta f
rom
Bel
gium
and
Ger
man
y bu
t re
sults
conf
irm
ed w
hen
mod
elle
d w
ith U
K d
ata.
150
151
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Wilk, A. I., Jensen, N. M. & Havighurst, T. C. (1997) Meta-analysis of randomised control trialsaddressing brief interventions in heavy alcohol drinkers, Journal of General Internal Medicine,Vol. 12, No. 5, pp. 274-283.
Williams, D. & McBride, A. J (1998) The drug treatment of alcohol withdrawal symptoms: asystematic review, Alcohol & Alcoholism, Vol. 33, No. 2, pp. 103-115.
Wutzke, S. E., Shiell, A., Gomel, M. K. & Conigrave K. M. (2001) Cost effectiveness of briefinterventions for reducing alcohol consumption, Social Science and Medicine, Vol. 52, No 6 pp.863-870.
Zwerling, C. & Jones M. P. (1999) Evaluation of the effectiveness of low blood alcoholconcentration laws for younger drivers, American Journal of Preventive Medicine, Vol. 16, No.1S, pp. 76S-80S.
163
ANNEX ONE SEARCH STRATEGIES
EFFECTIVENESS REVIEWS
MEDLINE (Ovid)
1. (systematic adj review$).tw.2. (data adj synthesis).tw.3. (published adj studies).ab.4. (data adj extraction).ab.5. meta-analysis/6. meta-analysis.ti.7. comment.pt.8. letter.pt.9. editorial.pt.10. animal/11. human/12. 10 not (10 and 11)13. alcoholism/14. 13 not (7 or 8 or 9 or 12)15. or/1-616. 14 and 1517. limit 16 to yr=1980-200118. alcohol drinking/19. 18 not (7 or 8 or 9 or 12)20. 15 and 1921. 20 not 1622. Health Behavior/23. Health Education/24. Health Promotion/25. preventive medicine/26. preventive health services/27. exp lifestyle/28. or/22-2729. 18 and 2830. Alcohol Drinking/dt, pc, px, th [Drug Therapy, Prevention & Control, Psychology, Therapy]31. 29 or 3032. 31 not (7 or 8 or 9 or 12)33. 15 and 3234. Alcoholic Intoxication/35. 28 and 3436. Alcoholic Intoxication/nu, dh, pc, px, rh, th [Nursing, Diet Therapy, Prevention & Control,Psychology, Rehabilitation,Therapy]37. 35 or 3638. 37 not (7 or 8 or 9 or 12)
164
39. 15 and 3840. Alcohol Deterrents/41. 40 not (7 or 8 or 9 or 12)42. 15 and 4143. ((drink$ or drunk$ or influence) adj (excessive or binge or heavy or hazard$ or problem$ orabuse or misuse)).tw.44. 43 not (7 or 8 or 9 or 12)45. 15 and 4446. intervention studies/47. intervention$.ti.48. 46 or 4749. 48 and (13 or 18 or 34)50. 49 not (7 or 8 or 9 or 12)51. 15 and 5052. temperance/53. 52 not (7 or 8 or 9 or 12)54. 15 and 5355. 16 or 21 or 39 or 42 or 45 or 51 or 5456. limit 55 to yr=1980-2001
EMBASE (Ovid)
1. (systematic adj review$).tw.2. (data adj synthesis).tw.3. (published adj studies).tw.4. (data adj extraction).ab.5. Meta Analysis/6. meta-analysis.ti.7. letter.pt.8. editorial.pt.9. animal/10. human/11. 9 not (9 and 10)12. alcoholism/13. 12 not (7 or 8 or 11)14. or/1-615. 13 and 1416. exp Alcohol Abuse/17. 16 not (7 or 8 or 11)18. health behavior/19. health education/ or health promotion/ or patient education/20. Preventive Medicine/21. Preventive Health Service/22. exp "Lifestyle and Related Phenomena"/23. Psychological Aspect/24. rehabilitation/ or drug dependence treatment/
165
25. exp Therapy/26. "prevention and control"/ or control/ or prevention/27. prevention/ or accident prevention/ or primary prevention/28. or/18-2729. 17 and 2830. 14 and 2931. alcohol intoxication/ or drunkenness/32. 31 not (7 or 8 or 11)33. 28 and 3234. 14 and 3335. Alcohol Consumption/36. 35 not (7 or 8 or 11)37. 28 and 3638. 14 and 3739. alcohol abstinence/ or drinking behavior/40. Alcoholics Anonymous/41. 39 or 4042. 41 not (7 or 8 or 11)43. 14 and 4244. ((drink$ or drunk$ or influence) adj (excessive or binge or heavy or hazard$ or problem$ orabuse or misuse)).mp. [mp=title, abstract, heading word, drug trade name, original title, drugmanufacturer name]45. 44 not (7 or 8 or 11)46. 14 and 4547. intervention.ti.48. (intervention$ adj stud$).ab.49. 47 or 4850. 49 and (12 or 16 or 31 or 35 or 39 or 40)51. 50 not (7 or 8 or 11)52. 14 and 5153. 15 or 30 or 34 or 38 or 43 or 46 or 52
CINAHL (Ovid)
1. (systematic adj review$).tw.2. (data adj synthesis).tw.3. (published adj studies).tw.4. (data adj extraction).ab.5. Meta Analysis/6. meta-analysis.ti.7. letter.pt.8. editorial.pt.9. animal/10. human/11. 9 not (9 and 10)12. alcoholism/
166
13. 12 not (7 or 8 or 11)14. or/1-615. 13 and 1416. exp Alcohol Abuse/17. 16 not (7 or 8 or 11)18. health behavior/19. health education/ or health promotion/ or patient education/20. Preventive Medicine/21. Preventive Health Service/22. exp "Lifestyle and Related Phenomena"/23. Psychological Aspect/24. rehabilitation/ or drug dependence treatment/25. exp Therapy/26. "prevention and control"/ or control/ or prevention/27. prevention/ or accident prevention/ or primary prevention/28. or/18-2729. 17 and 2830. 14 and 2931. alcohol intoxication/ or drunkenness/32. 31 not (7 or 8 or 11)33. 28 and 3234. 14 and 3335. Alcohol Consumption/36. 35 not (7 or 8 or 11)37. 28 and 3638. 14 and 3739. alcohol abstinence/ or drinking behavior/40. Alcoholics Anonymous/41. 39 or 4042. 41 not (7 or 8 or 11)43. 14 and 4244. ((drink$ or drunk$ or influence) adj (excessive or binge or heavy or hazard$ or problem$ orabuse or misuse)).mp. [mp=title, abstract, heading word, drug trade name, original title, drugmanufacturer name]45. 44 not (7 or 8 or 11)46. 14 and 4547. intervention.ti.48. (intervention$ adj stud$).ab.49. 47 or 4850. 49 and (12 or 16 or 31 or 35 or 39 or 40)51. 50 not (7 or 8 or 11)52. 14 and 5153. 15 or 30 or 34 or 38 or 43 or 46 or 52
PsychINFO (Silverplatter)
167
1. systematic2. review*3. systematic near review*4. data5. synthesis6. data near synthesis7. published8. studies9. published near studies10. data11. extraction12. data near extraction13. exact{META-ANALYSES}14. exact{META-ANALYSIS}15. #13 or #1416. "Meta-Analysis" in DE17. #3 or #6 or #9 or #12 or #13 or #14 or #1618. explode "Animals"19. "Drug-Education" in DE20. #17 and #1921. explode "Alcohol-Rehabilitation"22. #17 and #2123. #22 not #1824. "Sobriety-" in DE25. #17 and #2426. explode "Alcohol-Drinking-Patterns"27. #17 and #2628. "Alcohol-Drinking-Attitudes" in DE29. #17 and #2830. explode "Alcohol-Intoxication"31. #17 and #3032. alcohol33. drinking34. misuse35. abuse36. consum*37. intoxicat*38. alcoholism39. drinking40. behavio?r41. (alcohol and ( drinking or misuse or abuse or consum* or intoxicat* )) or alcoholism ordrinking behavio?r42. "Health-Behavior" in DE43. "Behavior-Change" in DE44. "Behavior-Modification" in DE45. explode "Lifestyle"46. "Health-Promotion" in DE
168
47. "Health-Education" in DE48. "Prevention-" in DE49. "Treatment-" in DE50. "Drug-Therapy" in DE51. "Rehabilitation-" in DE52. "Rehabilitation-Counseling" in DE53. #2 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or #50 or #51 or #5254. #17 and #41 and #5355. #20 or #22 or #25 or #27 or #29 or #31 or #54
Social Science Citation Index (Web of Science)2 strategies
1. ((alcohol and ( drinking or misuse or abuse or consum* or intoxicat*)) or alcoholism ordrinking behavio?r and (prevent* or educat* or interven* or treat* or therapy or rehabilitat*or deter*) and (systematic review* or data synthesis or published studies or data extraction ormeta analysis or meta-analysis)
2. ((alcohol or drinking) and (behavio?r* or pattern* or abstinence or temperance)) and
(systematic review* or data synthesis or published studies or data extraction or meta analysisor meta-analysis)
HMIC (Silverplatter)
1. exact {ALCOHOL}2. exact {ALCOHOL-}3. exact {ALCOHOL-ABUSE}4. exact {ALCOHOL-ABUSING}5. exact {ALCOHOL-CONSUMPTION}6. exact {ALCOHOL-CONTROL}7. exact {ALCOHOL-DEPENDENCE}8. exact {ALCOHOL-DEPENDENT}9. exact {ALCOHOL-DRINKING}10. exact {ALCOHOL-EDUCATION}11. exact {ALCOHOL-MISUSE}12. exact {ALCOHOL-MISUSE-SERVICES}13. exact {ALCOHOL-MISUSING}14. exact {ALCOHOL-POLICY}15. exact {ALCOHOL-PROBLEM-ADVISORY-SERVICE}16. exact {ALCOHOL-RELATED}17. exact {ALCOHOL-RELATED-DISEASES}18. exact {ALCOHOL-RELATED-MORTALITY}19. exact {ALCOHOL-RELATED-OFFENCES}20. exact {ALCOHOL-RELATED-PROBLEMS}21. exact {ALCOHOL-SERVICES}
169
22. exact {ALCOHOL-USE}23. exact {ALCOHOLICS}24. exact {ALCOHOLICS-}25. exact {ALCOHOLICS-ANONYMOUS}26. exact {ALCOHOLICS-UNITS}27. exact {ALCOHOLISM}28. exact {ALCOHOLISM-}29. exact {ALCOHOLISM-CONTROL}30. exact {ALCOHOLISM-RELATED}31. exact {ALCOHOLISM-RELATED-DISEASES}32. exact {ALCOHOLISM-TREATMENT}33. exact {DRINKING}34. exact {DRINKING-DRIVING}35. exact {DRINKING-HABITS}36. exact {DRINKING-LOCATIONS}37. exact {DRINKING-PATTERNS}38. exact {DRINKING-PROBLEM}39. exact {DRINKING-RELATED}40. or/#1-#3941. exact {SYSTEMATIC-ANALYSIS}42. exact {SYTEMATIC-REVIEW}43. exact {SYSTEMATIC-REVIEWS}44. exact {META-ANALYSES}45. exact {META-ANALYSIS}46. systematic near review*47. exact {DATA-EXTRACTION}48. data near extraction49. exact {DATA-SYNTHESIS}50. data near synthesis51. exact {LITERATURE}52. exact {LITERATURE-}53. exact {LITERATURE-BASED}54. exact {LITERATURE-EVALUATION}55. exact {LITERATURE-REVIEW}56. exact {LITERATURE-REVIEWS}57. exact {LITERATURE-SEARCHES}58. exact {LITERATURE-SEARCHING}59. published near studies60. or/#41-#5961. #40 and #6062. PY>=198063. #61 and #62
SIGLE (Blaise)
3 strategies
170
1. ((alcohol and ( drinking or misuse or abuse or consum: or intoxicat )) or alcoholism ordrinking behavio:r) and (prevent: or educat: or interven: or treat: or therapy or rehabilitat: ordeter:) and (systematic review: or data synthesis or published studies or data extraction ormeta analysis or meta-analysis)
2. ((alcohol or drinking) and (behavio:r: or pattern: or abstinence or temperance)) and
(systematic review: or data synthesis or published studies or data extraction or meta analysisor meta-analysis)
3. alcohol and (review or systematic review: or data synthesis or published studies or data
extraction or meta analysis or meta-analysis)
COST-EFFECTIVENESS REVIEW
SilverPlatterASCII 3.0WINNSelected Databases
"Economics"/ all subheadingsexplode "Costs-and-Cost-Analysis"/ all subheadings"Economic-Value-of-Life"explode "Economics-Hospital"/ all subheadingsexplode "Economics-Medical"/ all subheadings"Economics-Nursing"/ all subheadings"Economics-Pharmaceutical"/ all subheadingseconom* or cost or costs or costing or costly or price or prices or pricing or pharmacoecon* orpharmaco-econ* or (pharmaco econ*) or expense*value near1 moneybudget*expenditure* not energy#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11(letter or editorial or comment) in pt#12 not #13animal in tghuman in tg#15 not (#15 and #16)#14 not #17metabolic near cost(energy or oxygen) near cost#18 not (#19 or #20)"Alcoholism"/ all subheadings"Alcohol-Related-Disorders"/ all subheadings"Alcohol-Induced-Disorders"/ all subheadings"Alcoholic-Intoxication"/ all subheadings(problem* or binge* or excess* or heavy) near3 drink*(alcoholism or alcoholic*) in ti,ab,mesh
171
(alcohol* near3 (abuse* or misuse* or addict* or dependen* or problem*)) in ti,ab,mesh#22 or #23 or #24 or #25 or #26 or #27 or #28"Health-Promotion"/ all subheadings"Health-Education"/ all subheadings"Patient-Education"/ all subheadings"Health-Behavior"/ all subheadings"Patient-Compliance"/ all subheadings"Treatment-Refusal"/ all subheadingsexplode "Treatment-Outcome"/ all subheadings"Primary-Prevention"/ all subheadingsexplode "Rehabilitation"/ all subheadings"Rehabilitation-Centers"/ all subheadings"Substance-Abuse-Treatment-Centers"/ all subheadings"Cognitive-Therapy"/ all subheadings"Behavior-Therapy"/ all subheadingshealth near2 (promotion* or educat* or behavio?r*)(patient* near2 (educat* or behavio?r*)) or rehab* or detoxification* or de-tox* or acomposate*or Campral or Acamprosate or (cognitive behavio?ral) or (cognitive therap*)reduction or reduce* or reducing or therapy or therapies or therapeutic* or prevent* or interven*or treatment*psychological* or pharmacological*#30 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43or #44#45 or #46#21 and (#48 near5 #29)#21 and #29 and #47"Alcoholism"/ diet-therapy , drug-therapy , nursing , prevention-and-control , rehabilitation ,therapy"Alcoholism"/ economics#51 and #21#52 and #47#49 or #50 or #53 or #54#55 and (PY = 1990-2001)#56 and (LA = "ENGLISH")
172
ANNEX TWO STUDIES EXCLUDED FROM EFFECTIVENESS REVIEW
Aaronson, L. S. 1989, "Perceived and received support: effects on health behavior duringpregnancy", Nursing Research, vol. 38,no. 1, pp. 4-9.
Allensworth, D. D. 1994, "The research base for innovative practices in school health educationat the secondary level", Journal of School Health, vol. 64,no. 5, pp. 180-187.
Baucom, D. H., Mueser, K. T., Daiuto, A. D., & Stickle, T. R. 1998, "Empirically supportedcouple and family interventions for marital distress and adult mental health problems", Journal ofConsulting & Clinical Psychology Vol, vol. 66,no. 1, pp. 53-88.
Bensley, L. S. & Wu, R. 1991, "The role of psychological reactance in drinking followingalcohol prevention messages", Journal of Applied Social Psychology, vol. 21,no. 13, pp. 1111-1124.
Botvin, G. J., Baker, E., Dusenbury, L., Botvin, E. M., & Diaz, T. 1995, "Long-term follow-upresults of a randomized drug-abuse prevention trial in a white middle-class population", Journalof the American Medical Association, vol. 273,no. 14, pp. 1106-1112.
Chick, J., Howlett, H., Morgan, M. Y., & Ritson, B. 2000, "United Kingdom multicentreacamprosate study (UKMAS): A 6-month prospective study of acamprosate versus placebo inpreventing relapse after withdrawal from alcohol", Alcohol and Alcoholism, vol. 35,no. 2, pp.176-187.
Coggans, N. & Watson, J. 1995, "Drug education: Approaches, effectiveness and delivery",Drugs-Education Prevention and Policy, vol. 2,no. 3, pp. 211-224.
Connors, G. J. & Rounsaville, B. J. 1998, "Innovations in alcoholism treatment: state of the artreviews and", Addiction, vol. 93, pp. 1596-1597.
Crook, G. M. & Oei, T.-P. S. 1998, "A review of systematic and quantifiable methods ofestimating the needs of a community for alcohol treatment services", Journal of Substance AbuseTreatment p. of.
Dawson, D. A. 1999, "Alternative definitions of high risk for impaired driving: the overlap ofhigh volume, frequent heavy drinking and alcohol dependence", Drug and Alcohol Dependence,vol. 54,no. 3, pp. 219-228.
DeWit, D. J. & Rush, B. 1996, "Assessing the need for substance abuse services: A criticalreview of needs assessment models", Evaluation and Program Planning, vol. 19,no. 1, pp. 41-64.
Elmquist, D. L. 1995, "A systematic review of parent-oriented programs to prevent children’s useof alcohol and other drugs", Journal of Drug Education, vol. 25,no. 3, pp. 251-279.
173
Emshoff, J. G. & Price, A. W. 1999, "Prevention and intervention strategies with children ofalcoholics", Pediatrics, vol. 103,no. 5, pp. 1112-1121.
Flowers, L. K. & Zweben, J. E. 1998, "The changing role of "using" dreams in addictionrecovery", Journal of Substance Abuse Treatment, vol. 15,no. 3, pp. 193-200.
Gerrity, M. S. 2001, "Interventions to improve physicians’ well-being and patient care: acommentary", Social Science & Medicine, vol. 52,no. 2, pp. 223-225.
Gorenc, K. D., Peredo, S., Pacurucu, S., Llanos, R., Vincente, B., Lopez, R., Abreu, L. F., &Paez, E. 1999, "Validation of the Cross-Cultural Alcoholism Screening Test (CCAST)", Archivesof Medical Research, vol. 30,no. 5, pp. 399-410.
Hall, W. & Zador, D. 1997, "The alcohol withdrawal syndrome", Lancet, vol. 349,no. 9069, pp.1897-1900.
Hansen, W. B. & McNeal, R. B. 1999, "Drug education practice: results of an observationalstudy", Health Education Research, vol. 14,no. 1, pp. 85-97.
Hayashida, M. 1998, "An overview of outpatient and inpatient detoxification", Alcohol Health &Research World, vol. 22,no. 1, pp. 44-46.
Henderson-Martin, B. 2000, "No more surprises: screening patients for alcohol abuse", AmericanJournal of Nursing, vol. 100,no. 9, pp. 26-33.
Hertzman, M. 2000, "Divalproex sodium to treat concomitant substance abuse and mooddisorders", Journal of Substance Abuse Treatment p. of.
Howard, M. O., Kivlahan, D., & Walker, R. D. 1997, "Cloninger’s tridimensional theory ofpersonality and psychopathology: Applications to substance use disorders", Journal of Studies onAlcohol, vol. 58,no. 1, pp. 48-66.
Howell, E. M., Heiser, N., & Harrington, M. 1999, "A review of recent findings on substanceabuse treatment for pregnant women", Journal of Substance Abuse Treatment, vol. 16,no. 3, pp.195-219.
Howland, J., Mangione, T. W., Lee, M., Bell, N., & Levine, S. 1996, "Employee attitudes towardwork-site alcohol testing", Journal of Occupational and Environmental Medicine, vol. 38,no. 10,pp. 1041-1046.
Hughes, J. R. 1995, "Combining behavioral therapy and pharmacotherapy for smoking cessation:An update", NIDA Research Monograph Issue, vol. 150,no. pp 92-109.
Kaminer, Y. 1995, "Issues in the pharmacological treatment of adolescent substance abuse",Journal of Child and Adolescent Psychopharmacology, vol. 5,no. 2, pp. 93-106.
174
Larimer, M. E., Palmer, R. S., & Marlatt, G. A. 1999, "Relapse prevention: an overview ofMarlatt’s Cognitive-Behavioral Model", Alcohol Health & Research World, vol. 23,no. 2, pp.151-160.
Lennox, R. D., Steele, P. D., Zarkin, G. A., & Bray, J. W. 1998, "The differential effects ofalcohol consumption and dependence on adverse alcohol-related consequences: implications forthe workforce", Drug and Alcohol Dependence, vol. 50,no. 3, pp. 211-220.
McLellan, A. T., Hagan, T. A., Levine, M., Meyers, K., Gould, F., Bencivengo, M., Durell, J., &Jaffe, J. 1999, "Does clinical case management improve outpatient addiction treatment", Drugand Alcohol Dependence, vol. 55,no. 1-2, pp. 91-103.
Modesto-Lowe, V., Burleson, J. A., Hersh, D., Bauer, L. O., & Kranzler, H. R. 1997, "Effects ofnaltrexone on cue-elicited craving for alcohol and cocaine", Drug and Alcohol Dependence, vol.49,no. 1, pp. 9-16.
Moyers, P. A. & Barrett, C. E. 1992, "Neurocognition and alcoholism: implications foroccupational therapy", Occupational Therapy in Health Care, vol. 8,no. 2-3, pp. 87-115.
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O’Neal, K. J. 1993, "Anticipatory guidance: alcohol, adolescents, and recognizing abuse anddependence", Issues in Comprehensive Pediatric Nursing, vol. 16,no. 4, pp. 207-218.
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Smart, R. G. & Mann, R. E. 1997, "Interventions into alcohol problems: What works? Reply",Addiction, vol. 92,no. 1, pp. 9-13.
Thornton, C. C., Gottheil, E., Weinstein, S. P., & Kerachsky, R. S. 1998, "Patient-treatmentmatching in substance abuse - Drug addiction severity", Journal of Substance Abuse Treatment,vol. 15,no. 6, pp. 505-511.
Turner, W. M., Turner, K. H., Reif, S., Gutowski, W. F., & Gastfriend, D. R. 1999, "Feasibilityof multidimensional substance abuse treatment matching: automating the ASAM PatientPlacement Criteria", Drug and Alcohol Dependence, vol. 55,no. 1-2, pp. 35-43.
van den Bree, M. B. M., Johnson, E. O., Neale, M. C., Svikis, D. S., McGue, M., & Pickens, R.W. 1998, "Genetic analysis of diagnostic systems of alcoholism in males", Biological Psychiatry,vol. 43,no. 2, pp. 139-145.
175
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