cording to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, criteria; and (3) either. Results: Of 393 eligible patients, 243 (62%) completed AUDIT-C and interviews. For detecting heavy drinking, AUDIT-C had a higher AUROC than the full AUDIT (0.891 vs 0.881; P = .03). Although the full AUDIT performed better than AUDIT-C for detecting active alcohol abuse or dependence (0.811 vs 0.786; P<.001), the 2 questionnaires performed similarly for detecting heavy drinking and/or active abuse or dependence (0.880 vs 0.881).

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/208954/ioi70602.pdf

The AUDIT Alcohol consumption questions (AUDIT-C) : An effective brief screening test for problem drinking

Background Current and comprehensive information on the epidemiology of DSM-IV 12-month and lifetime drug use disorders in the United States has not been available. Objectives To present detailed information on drug abuse and dependence prevalence, correlates, and comorbidity with other Axis I and II disorders. Design, Setting, and Participants Face-to-face interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule of the National Institute on Alcohol Abuse and Alcoholism in a large representative sample of US adults (N = 43 093). Main Outcome Measures Twelve-month and lifetime prevalence of drug abuse and dependence and the associated correlates, treatment rates, disability, and comorbidity with other Axis I and II disorders. Results Prevalences of 12-month and lifetime drug abuse (1.4% and 7.7%, respectively) exceeded rates of drug dependence (0.6% and 2.6%, respectively). Rates of abuse and dependence were generally greater among men, Native Americans, respondents aged 18 to 44 years, those of lower socioeconomic status, those residing in the West, and those who were never married or widowed, separated, or divorced (all P Conclusions Most individuals with drug use disorders have never been treated, and treatment disparities exist among those at high risk, despite substantial disability and comorbidity. Comorbidity of drug use disorders with other substance use disorders and antisocial personality disorder, as well as dependence with mood disorders and generalized anxiety disorder, appears to be due in part to unique factors underlying each pair of these disorders studied. The persistence of low treatment rates despite the availability of effective treatments indicates the need for vigorous educational efforts for the public and professionals.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/482282/yoa60081_566_576.pdf

Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions

Background Motivational Interviewing is a well-known, scientifically tested method of counselling clients developed by Miller and Rollnick and viewed as a useful intervention strategy in the treatment of lifestyle problems and disease.

Aim To evaluate the effectiveness of motivational interviewing in different areas of disease and to identify factors shaping outcomes.

Design of study A systematic review and meta-analysis of randomised controlled trials using motivational interviewing as the intervention.

Method After selection criteria a systematic literature search in 16 databases produced 72 randomised controlled trials the first of which was published in 1991. A quality assessment was made with a validated scale. A meta-analysis was performed as a generic inverse variance meta-analysis.

Results Meta-analysis showed a significant effect (95% confidence interval) for motivational interviewing for combined effect estimates for body mass index, total blood cholesterol, systolic blood pressure, blood alcohol concentration and standard ethanol content, while combined effect estimates for cigarettes per day and for HbA1c were not significant. Motivational interviewing had a significant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases. Psychologists and physicians obtained an effect in approximately 80% of the studies, while other healthcare providers obtained an effect in 46% of the studies. When using motivational interviewing in brief encounters of 15 minutes, 64% of the studies showed an effect. More than one encounter with the patient ensures the effectiveness of motivational interviewing.

Conclusion Motivational interviewing in a scientific setting outperforms traditional advice giving in the treatment of a broad range of behavioural problems and diseases. Large-scale studies are now needed to prove that motivational interviewing can be implemented into daily clinical work in primary and secondary health care.

Motivational interviewing: a systematic review and meta-analysis

Background: The Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questions have been previously validated as a 3-item screen for alcohol misuse and implemented nationwide in Veterans Affairs (VA) outpatient clinics. However, the AUDIT-C's validity and optimal screening threshold(s) in other clinical populations are unknown.

Methods: This cross-sectional validation study compared screening questionnaires with standardized interviews in 392 male and 927 female adult outpatients at an academic family practice clinic from 1993 to 1994. The AUDIT-C, full AUDIT, self-reported risky drinking, AUDIT question #3, and an augmented CAGE questionnaire were compared with an interview primary reference standard of alcohol misuse, defined as a Diagnostic and Statistical Manual, 4th ed. alcohol use disorder and/or drinking above recommended limits in the past year.

Results: Based on interviews with 92% of eligible patients, 128 (33%) men and 177 (19%) women met the criteria for alcohol misuse. Areas under the receiver operating characteristic curves (AUROCs) for the AUDIT-C were 0.94 (0.91, 0.96) and 0.90 (0.87, 0.93) in men and women, respectively (p=0.04). Based on AUROC curves, the AUDIT-C performed as well as the full AUDIT and significantly better than self-reported risky drinking, AUDIT question #3, or the augmented CAGE questionnaire (p-values <0.001). The AUDIT-C screening thresholds that simultaneously maximized sensitivity and specificity were ≥4 in men (sensitivity 0.86, specificity 0.89) and ≥3 in women (sensitivity 0.73, specificity 0.91).

Conclusions: The AUDIT-C was an effective screening test for alcohol misuse in this primary care sample. Optimal screening thresholds for alcohol misuse among men (≥4) and women (≥3) were the same as in previously published VA studies.

AUDIT-C as a Brief Screen for Alcohol Misuse in Primary Care

Excessive drinking contributes significantly to social problems, physical and psychological illness, injury and death Hidden effects include increased levels of violence, accidents and suicide Most alcohol-related harm is caused by excessive drinkers whose consumption exceeds recommended drinking levels, not the drinkers with severe alcohol dependency problems One way to reduce consumption levels in a community may be to provide a brief intervention in primary care over one to four sessions This is provided by healthcare workers such as general physicians, nurses or psychologists In general practice, patients are routinely asked about alcohol consumption during registration, general health checks and as part of health screening (using a questionnaire) They tend not to be seeking help for alcohol problems when presenting The intervention they are offered includes feedback on alcohol use and harms, identification of high risk situations for drinking and coping strategies, increased motivation and the development of a personal plan to reduce drinking It takes place within the time-frame of a standard consultation, 5 to 15 minutes for a general physician, longer for a nurseA total of 29 controlled trials from various countries were identified, in general practice (24 trials) or an emergency setting (five trials) Participants drank an average of 306 grams of alcohol (over 30 standard drinks) per week on entry to the trial Over 7000 participants with a mean age of 43 years were randomised to receive a brief intervention or a control intervention, including assessment only After one year or more, people who received the brief intervention drank less alcohol than people in the control group (average difference 38 grams/week, range 23 to 54 grams) For men (some 70% of participants), the benefit of brief intervention was a difference of 57 grams/week, range 25 to 89 grams (six trials) The benefit was not clear for women The benefits of brief intervention were similar in the normal clinical setting and in research settings with greater resources Longer counselling had little additional benefit

/pdf/effectiveness-of-brief-alcohol-interventions-in-primary-care-4v9jy63xfu.pdf

Effectiveness of brief alcohol interventions in primary care populations

Objective. —Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers. Design. —Randomized controlled clinical trial with 12-month follow-up. Setting. —A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties. Participants. —Of the 17 695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures. Intervention. —The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information. Main Outcome Measures. —Alcohol use measures, emergency department visits, and hospital days. Results. —There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls;t=4.33;P Conclusions. —This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.

Brief Physician Advice for Problem Alcohol Drinkers A Randomized Controlled Trial in Community-Based Primary Care Practices

Background: Primary care settings are an ideal system in which to identify and treat substance use disorders. Objective: To ascertain the prevalence of tobacco, alcohol, and drug use in the office of 88 primary care clinicians by gender, age and ethnicity. Method: 21,282 adults ages 18-65 completed a self-administered Health Screening Survey while participating in a trial for early alcohol treatment. Results: The period prevalence of tobacco use was 27%. For alcohol: abstainers 40%, low risk drinkers 38%, at-risk drinkers 9%, problem drinkers 8%, and dependent drinkers 5%. Twenty percent of the sample reported using illicit drugs five or more times in their lifetime and 5% reported current illicit drug use. There were marked differences in alcohol use disorders by age and ethnicity. The majority of persons who smoked reported the desire to cut down or stop using tobacco. Significance: This is the first report on the combined prevalence of tobacco, alcohol and drug disorders in a large sample of p...

Tobacco, alcohol, and drug use in a primary care sample: 90-day prevalence and associated factors.

OBJECTIVES: This study was designed to determine the prevalence of at-risk drinking using varying alcohol use criteria. METHODS: A period prevalence survey was conducted in 22 primary care practices (n = 19372 adults). RESULTS: The frequency of at-risk alcohol use varied from 7.5% (World Health Organization criteria) to 19.7% (National Institute on Alcohol Abuse and Alcoholism criteria). A stepwise logistic model using National Institute on Alcohol Abuse and Alcoholism criteria found male gender, current tobacco use, never married status, retirement, and unemployment to be significant predictors of at-risk alcohol use. CONCLUSIONS: Public health policy needs to move to a primary care paradigm focusing on identification and treatment of at-risk drinkers.

Kristen Johnson

Papers

Brief Physician Advice for Problem Alcohol Drinkers A Randomized Controlled Trial in Community-Based Primary Care Practices

Tobacco, alcohol, and drug use in a primary care sample: 90-day prevalence and associated factors.

At-risk drinking in an HMO primary care sample: prevalence and health policy implications.