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 ³ 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.
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.
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.
Sponsors
The Canadian Task Force on Preventive Health
Care developed this guideline with funding from Health Canada.
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.