CTF Structured Abstract: Problem Drinking

Canadian Task Force on Preventive Health Care

Structured Abstract

Early Detection and Counselling of Problem Drinking

Prepared by Jean L. Haggerty, MSc, McGill University, Montreal, Quebec

These recommendations were finalized by the Task Force in March 1994

Objective
Burden of Suffering
Options
Outcomes

Evidence
Values
Benefits, Harms, and Costs
Recommendations

Validation
Sponsors
Selected References

Objective

To make recommendations about routine screening and counselling for ‘problem drinking’ behaviour in Canadian men and women. The focus is problem drinking or mild to moderate alcohol dependency.

Burden of Suffering

Alcohol consumption patterns that put patients at high risk of physical, psychological or social consequences are termed problem, hazardous, harmful, heavy, or excessive drinking, or mild to moderate alcohol dependency. Severe alcohol dependency is present in 5-10% of the population, and problem drinking in 15-25%. In spite of the incidence of severe alcohol dependency, the per capita consumption of alcohol in Canada has been steadily decreasing since 1981, and the decrease has been paralleled by a concomitant decrease in rates of mortality from alcoholic liver cirrhosis and other possibly alcohol-related mortality such as suicide, upper gastrointestinal and respiratory cancers, duodenal and stomach ulcers, pneumonia, and accidents.

Options

Screening options included: medical history-taking questions about quantity and frequency of alcohol consumption or use of 2 standard questions - "Have you ever had a drinking problem?" and "Have you had a drink in the last 24 hours?"; standardized questionnaires [Michigan Alcoholism Screening Test (MAST), CAGE query, Alcohol Use Disorders Identification Test (AUDIT)]; and biomarkers [gamma-glutamyl transferase (GGT)].

Counselling techniques were ‘simple advice’, defined as a 5-minute session including feedback on screening results, clarification of the association between excessive drinking and negative consequences and advice on reducing consumption; and ‘brief counselling’, defined as a session of ł 15 minutes consisting of problem clarification, goal setting and discussion on how to reduce consumption. The treatment goal is controlled drinking.

Alternative components of interventions are self-help pamphlets, regular follow up visits and objective laboratory biomarkers.

Outcomes

Health outcomes were alcohol consumption, mortality and hospital days. Test properties were sensitivity and specificity.

Evidence

MEDLINE was searched from 1989 to October 1993 using the MeSH headings "alcoholism" and "alcohol drinking", with sub-headings "epidemiology", "prevention & control", "therapy" and "rehabilitation". Only original studies published in English or French were included. Study results were synthesized in table or graphic format only.

Recommendations were graded as:

A Good evidence to support the recommendation that the condition be specifically considered in a PHE.

B Fair evidence to support the recommendation that the condition be specifically considered in a PHE.

C Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.

D Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

E Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

Quality of evidence was rated according to 5 levels:

I Evidence from at least 1 properly randomized controlled trial (RCT).

II-1 Evidence from well-designed controlled trials without randomization.

II-2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.

II-3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.

III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Values

The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs

Test Properties

The MAST is a 20-minute, 25-item questionnaire with reported sensitivities of 59% to 100% and specificities of 54% to 95%.

The CAGE, a 4-item query, has a sensitivity of 75% to 89% and specificity of 68% to 96%. Lower sensitivities were found when in populations where the prevalence of problem drinking was low. In this case, these populations (e.g. pre-natal patients), quantity-frequency queries detect more problem drinkers than MAST or CAGE.

CAGE and MAST were designed to detect severe alcohol dependency rather than problem drinking. Other limitations are the inclusion of questions on lifetime occurrence of problem drinking (which doesn’t distinguish present and past problems) and the absence of questions on binge drinking, a sensitive indicator for women and inner-city populations.

The AUDIT, a 10-item instrument specifically designed to detect problem drinkers, had consistent, average sensitivities of 80% and specificities of 98%.

Biomarker testing with GGT has poor sensitivity (40% to 52%) and specificity (78% to 89%).

Interventions

Several RCTs confirm that routine screening and counselling are effective in reducing alcohol consumption and related problems.

In Scandinavia, a population-based trial of men and women aged 17 to 62 years (excluding alcoholics) found that heavy drinkers who were advised to reduce alcohol consumption and monitored (intervention group) experienced a statistically significant decrease in GGT levels and self-reported consumption. In another Scandinavian study of middle aged men (one third of whom were alcoholics), GGT levels decreased significantly in both experimental and control groups. (Note that the control group received a letter advising a reduction in alcohol consumption.) However, after 5 years, the experimental group had a 61% reduction in hospital days and a 50% reduction in mortality.

In one of two UK primary care studies of men and women aged 17 to 69 years, persons allocated to the intervention group were referred to their general practitioner who provided feedback, advice and a self-help pamphlet on reducing alcohol consumption. At 1 year follow-up, alcohol consumption of 45% of the intervention group showed decreased alcohol consumption, to target levels compared with 25% of controls. In the other study, decreases of 18% and 5% respectively were found. The greater reductions found in the first study may be attributed to the inclusion of heavy drinkers in the study sample.

In the WHO Collaborative Project on Identification and Management of Alcohol-Related Problems, 1559 problem drinkers aged 19-70 years in 8 countries were randomly assigned to one of 2 intervention groups (‘simple advice’ or ‘brief counselling’) or to the control group. Of the 75% of subjects assessed at a 9 month follow-up, self-reported drinking had decreased in all groups, and men in both intervention groups reported a significantly greater reduction in typical daily consumption and drinking intensity than did controls. No significant differences were found for women, or between ‘simple advice’ and ‘brief counselling’ groups.

Potential harms and costs were not described.

Recommendations

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

There is fair evidence to include (in the PHE) routine detection using standardized questionnaires and/or patient enquiry, and brief counselling for those identified with ‘problem drinking’ [B, I]. Use of biomarkers for screening purposes is not recommended.

Validation

This report was externally peer-reviewed. These recommendations are consistent with those of the United States Preventive Services Task Force and the College of Family Physicians of Canada.

Recommendations about routine screening and counselling are consistent with those of the 1989 U.S. Preventive Services Task Force, the Alcohol Risk Assessment and Intervention Project of College of Family Physicians of Canada, and the Institute of Medicine, with some variation in the statement of the target population.

Selected References

Source Document

Haggerty JL. Early detection and counselling of problem drinking. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 488-98.

Link to Full Text of this review

Link to Summary Table of Recommendations of this review

Link to Selected References list of this review

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A	Good evidence to support the recommendation that the condition be specifically considered in a PHE.
B	Fair evidence to support the recommendation that the condition be specifically considered in a PHE.
C	Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D	Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.
E	Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

I	Evidence from at least 1 properly randomized controlled trial (RCT).
II-1	Evidence from well-designed controlled trials without randomization.
II-2	Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3	Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III	Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.