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Making it work together Effective and Cost-Effective Measures to Reduce Alcohol Misuse in Scotland

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Page 1: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

Making it work together

Effective and Cost-Effective Measures to Reduce

Alcohol Misuse in Scotland

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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

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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

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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

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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

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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.

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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.

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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.

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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

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• 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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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.

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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,

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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.

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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)

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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

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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

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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.

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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.

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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.

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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.

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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.

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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

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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).

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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

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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.

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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

.

Page 34: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

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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).

Page 36: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL
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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-

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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).

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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

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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

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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.

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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

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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

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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

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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.

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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:

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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).

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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.

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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.

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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.

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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.

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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.

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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

Page 54: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

.

Page 55: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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,

Page 56: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 57: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 58: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 59: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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.

Page 60: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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.

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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.

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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

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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.

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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.

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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

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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.

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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.

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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.

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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

.

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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

lope

d w

ith th

e W

HO

colla

bora

tive

stud

y fo

r ea

rly

inte

rven

tions

for

’at r

isk’

alco

hol c

onsu

mpt

ion.

GPs

agr

eein

g to

use

Dri

nk-l

ess

pack

age.

No

anal

ysis

of

whe

ther

use

dor

hea

lth o

utco

mes

Tel

emar

keti

ng a

ppea

red

to b

e th

e m

ost c

ost-

effe

ctiv

em

eans

of

pers

uadi

ng G

Ps to

rec

eive

and

em

ploy

the

drin

kles

s pa

ckag

e. 6

4 of

the

87 G

Ps c

onta

cted

agre

ed to

rec

eive

the

pack

age.

The

cos

t per

doc

tor

rece

ivin

g w

as $

3.97

. D

irec

t mai

l cos

t $10

per

doc

tor

agre

eing

and

per

sona

l mar

ketin

g co

st $

20.3

6.

Tol

ley

K,

Row

land

N.

Iden

tific

atio

n of

alco

hol-

rela

ted

prob

lem

s in

age

nera

l hos

pita

lse

tting

: A c

ost-

effe

ctiv

enes

sev

alua

tion.

Bri

tish

Jour

nal o

fA

ddic

tion.

1991

;86

:429

-38.

Part

ial

eval

uatio

n H

ealt

h ca

repr

ofes

sion

als

deliv

erin

gin

terv

entio

ns to

alco

holi

cs -

UK

Alc

ohol

scr

eeni

ng f

orpa

tient

s N

umbe

r of

scr

eeni

ngs.

As

a pe

rcen

tage

of

adm

issi

ons

(pos

itive

scre

enin

gs in

pare

nthe

ses)

, nur

ses

scre

ened

48%

(7.

8%),

doct

ors

27%

(9.

8%)

and

the

spec

iali

st w

orke

r 21

%(1

2.5%

).

In te

rms

of th

e lo

wes

t cos

t per

pos

itive

scr

eeni

ng,

doct

ors

cost

£1.

17, c

ompa

red

to £

1.20

for

the

spec

ialis

t wor

ker

and

£1.2

9 fo

r nu

rses

.C

ombi

natio

ns o

f op

tions

sho

w th

at th

e lo

wes

t cos

tpe

r sc

reen

ing

is w

hen

nurs

es s

cree

n al

l pat

ient

s, th

egr

eate

st r

ate

of p

ositi

ve s

cree

ning

s w

hen

a sp

ecia

list

wor

ker

scre

ens

all p

atie

nts,

and

low

est a

vera

ge c

ost

per

posi

tive

scre

enin

g w

hen

doct

ors

scre

en a

llpa

tient

s or

doc

tors

scr

een

mal

e pa

tient

s an

d nu

rses

scre

en f

emal

e pa

tien

ts. M

argi

nal c

ost a

naly

sis

base

don

the

addi

tiona

l pos

itive

cas

es id

entif

ied

per

1000

scre

enin

gs o

f di

ffer

ent c

ombi

natio

ns o

f he

alth

car

epr

ofes

sion

als

deliv

erin

g th

e in

terv

entio

ns.

By

empl

oyin

g a

spec

iali

st w

orke

r co

mpa

red

to a

nur

se,

the

spec

ialis

t wor

ker

wou

ld id

entif

y ad

ditio

nal 8

8ca

ses

per

1000

adm

issi

ons

at a

mar

gina

l cos

t per

posi

tive

case

iden

tifie

d of

£0.

56.

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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.

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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.

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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).

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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

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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).

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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.

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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

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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.

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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

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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.

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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

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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.

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Tab

le 8

.7Su

mm

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of B

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Int

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ffec

tive

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Qua

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And

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.E

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of

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tions

for

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with

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ctic

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3: 3

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.

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rest

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and

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the

prop

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this

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and

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as g

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. 3

out

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6 st

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und

sign

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to m

oder

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.P

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was

gre

ater

than

or

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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

Page 84: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 85: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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)

Page 86: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 87: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 88: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 89: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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.

Page 90: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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.

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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).

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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.

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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

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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.

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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

Page 96: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

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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.

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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.

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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

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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).

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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

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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

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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

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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)

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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.

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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.

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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.

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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

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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

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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).

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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

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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.

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tios

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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

Page 114: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 115: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 116: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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).

Page 117: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 118: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 119: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 120: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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.

Page 121: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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.

Page 122: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 123: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 124: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 125: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 126: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

.

Page 127: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 128: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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,

Page 129: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

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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.

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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.

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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.

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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)

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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.

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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.

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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

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ate

Sear

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rate

gy In

clus

ion

/E

xclu

sion

Cri

teri

a Q

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sess

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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

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rep

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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

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with

prob

lem

dri

nker

s. T

here

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w s

tudi

es a

nd th

ese

indi

cate

dre

lativ

ely

few

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alc

ohol

. L

ittle

atte

ntio

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as g

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to a

sses

smen

t and

clin

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ski

lls in

this

are

a. T

here

is m

ore

relia

nce

on s

peci

alis

ed p

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regi

stra

tion

cour

ses.

Col

anto

nio

AA

sses

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the

effe

cts

ofem

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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

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unpu

blis

hed

man

uscr

ipts

,co

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d pu

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atio

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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

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s).

The

pro

vide

r w

as n

ot a

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s sp

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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

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in a

tle

ast 3

9% o

f st

udie

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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

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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

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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

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py w

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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.

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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.

Page 138: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

Page 139: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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.

Page 140: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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.

Page 141: Effective and Cost-Effective Measures to Reduce Alcohol ...docs.scie-socialcareonline.org.uk/fulltext/alcreducerevfull.pdf · EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL

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

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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

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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

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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.

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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.

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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

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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.

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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.

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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.

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Miller, W. R., Andrews, N. R., Wilbourne, P. & Bennett, M. E. (1998) A wealth of alternatives.Effective treatments for alcohol problems. In Miller, W. R. and Heather, N. (eds) TreatingAddictive Behaviours. 2nd ed. Plenum Press, New York

Modesto-Lowe, V. & Boornazian, A. (2000) Screening and brief intervention in the managementof early problem drinkers: Integration into health care settings. Disease Management & HealthOutcomes. Vol 8, No 3, pp 129-37

Monahan, S. C. & Finney, J. W (1996) Explaining abstinence rates following treatment foralcohol abuse: A quantitative synthesis of patient, research design and treatment effects,Addiction, Vol. 91, No. 6, pp. 787-805.

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Netten, A., and Curtis, L. (2000) Unit Costs of Health and Social Care 2000 Personal SocialServices Research Unit, University of Kent at Canterbury, 2000

NIAAA (National Institute on Alcohol Abuse and Alcoholism) (2000) 10th Special Report to theUS Congress on Alcohol and Health. US Department of Health and Human Sciences.

O’Connor, P. G. & Schottenfeld, R. S, (1998) Patients with alcohol problems, New EnglandJournal of Medicine, Vol. 338, No. 9, pp. 592-602.

O’Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Brown, E., Bayog, R., McCourt, W., Lowe, J.,Chan, A. & Denault, P. (1996a) Cost-benefit and cost-effectiveness analyses of behaviouralmarital therapy with and without replase prevention sessions for alcoholics and their spouses,Behavior Therapy, Vol. 27, pp. 7-24.

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Poikolainen, K. (1999) Effectiveness of brief interventions to reduce alcohol intake in primaryhealth care populations: a meta-analysis, Preventive Medicine, Vol. 28, No. 5, pp. 503-509.

Raistrick, D., Hodgeson, R. & Ritson, B. (1999) Tackling alcohol together: The evidence basefor UK alcohol policy, London: Free Association Books.

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Rivara, F. P., Thompson, D. C., Beahler, C. & MacKenzie, E. J. (1999) Systematic reviews ofstrategies to prevent motor vehicle injuries. American Journal of Preventive Medicine Vol 16,No 1S, pp1-5

Roche, A. M. (1998) Alcohol and drug education and training: A review of key issues, Drugs:Education, Prevention and Policy. Vol. 5, No. 1, pp. 85-99.

Roman, P. M. & Blum, T. C. (1996) Alcohol: a review of the impact of worksite interventions onhealth and behavioural outcomes, American Journal of Health Promotion, Vol. 11, No. 2, pp.136-149.

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Samet, J. H., Friedmann, P., & Saitz, R. (2001) Benefits of linking primary medical care andsubstance abuse services - Patient, provider, and societal perspectives, Archives of InternalMedicine, Vol. 161, No. 1, pp. 85-91.

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Teitelbaum, L. & Mullen, B. (2000) The validity of the MAST in psychiatric settings: a meta-analytic integration. Journal of Studies on Alcohol. Vol 61, pp 254-61

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Walitzer, K. S. & Connors, G. J. (1999) Treating problem drinking, Alcohol Research andHealth, Vol. 32, No. 2, pp. 138-143.

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Wilde, M. I. & Wagstaff, A. J. (1997) Acamprosate: A review of its pharmacology and clinicalpotential in the management of alcohol dependence after detoxification. Drugs. Vol 53, No 6, pp1038-53.

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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)

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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/

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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/

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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)

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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

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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}

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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

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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

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(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")

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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.

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