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Can alcohol consumption in Germany be reduced by alcohol screening, brief intervention and referral to treatment in primary health care? Results of a simulation study

Jakob Manthey1, Adriana Solovei2, Peter J. Anderson3, Sinclair Carr4, Jürgen Rehm5 •
Dresden University of Technology1, Maastricht University2, Newcastle University3, University of Hamburg4, Centre for Addiction and Mental Health5
20 May 2021-medRxiv (Cold Spring Harbor Laboratory Press)-
TL;DR: In this article, the authors developed an open-access simulation model to estimate the impact of higher SBIRT delivery rates in German primary health care settings on population-level alcohol consumption.
Abstract: Background Screening, brief intervention and referral to treatment (SBIRT) is a programme to reduce alcohol consumption for drinkers with high alcohol consumption levels. Only 2.9% of patients in primary health care (PHC) are screened for their alcohol use in Germany, despite high levels of alcohol consumption and attributable harm. We developed an open-access simulation model to estimate the impact of higher SBIRT delivery rates in German PHC settings on population-level alcohol consumption. Methods and findings A hypothetical population of drinkers and non-drinkers was simulated by sex, age, and educational status for the year 2009 based on survey and sales data. Risky drinking persons receiving BI or RT were sampled from this population based on screening coverage and other parameters. Running the simulation model for a ten-year period, drinking levels and heavy episodic drinking (HED) status were changed based on effect sizes from meta-analyses. In the baseline scenario of 2.9% screening coverage, 2.4% of the adult German population received a subsequent intervention between 2009 and 2018. If every second PHC patient would have been screened for alcohol use, 21% of adult residents in Germany would have received BI or RT by the end of the ten-year simulation period. In this scenario, population-level alcohol consumption would be 12% lower than it was in 2018, without any impact on HED prevalence. Screening coverage rates below 10% were not found to have a measurable effect on drinking levels. Conclusions Large-scale implementation of SBIRT in PHC settings can yield substantial reductions of alcohol consumption in Germany. As high screening coverage rates may only be achievable in the long run, other effective alcohol policies are required to achieve short-term reduction of alcohol use and attributable harm in Germany. There is large potential to apply this open-access simulation model to other settings and for other alcohol interventions.

Summary (4 min read)

Jump to: [Introduction] – [Attenuation of effects] – [Step 2: Simulating baseline alcohol consumption in the population] – [Step 3: Applying effects of SBIRT] – [Step 4: Accounting for secular changes and attenuating intervention effects] – [Sensitivity analysis] – [Reporting the simulation findings] – [Alcohol exposure in Germany in the baseline scenario] – [Estimated coverage of SBIRT] – [Impact on APC and HED] – [Sensitivity analyses] – [Limitations] – [Comparison with other simulation studies] and [Implications for alcohol policy in Germany]

Introduction

  • Globally, alcohol use is a major risk factor for the burden of mortality and disease [1, 2] .
  • Various initiatives have been set by the World Health Organization (WHO) and the United Nations has set objectives to reduce this burden [3] .
  • The only application of a simulation model to quantify the effects of SBI in Germany known to the authors was carried out as part of a report issued by the Organization for Economic Co-operation and Development [17] .
  • In fact, none of the 22 studies identified in the 2014 review disclosed their simulation programmes [16] .

Attenuation of effects

  • The attenuation of intervention effects, assuming that BI effects to remain stable for a period of four years and to attenuate thereafter and reach 0 after ten years (linearly imputed for all years five to ten) according to [25] and [26].
  • Lastly, sex, age, and education stratified population data for all years was obtained by combining population data from UN (providing data for all age groups and years, but not by education) and EUROSTAT (providing education breakup for all years, but only for age groups up to 74 years).
  • As a result, the authors obtained a complete set of prevalence estimates for lifetime abstinence, former drinking, current drinking, and HED, as well as average drinking levels per drinker -for all years 2009 to 2018 and by sex, age, and education.
  • These data served as input data for the next step.

Step 2: Simulating baseline alcohol consumption in the population

  • For the year 2009, a population sample of 100 persons was drawn, stratified by sex, age, and educational level.
  • Using binomial distributions, the drinking status prevalence estimates described in step 1 were used to determine the drinking status (either lifetime abstainer, former drinker, or current drinker) for each person.
  • Second, the authors determined daily drinking levels (in grams pure alcohol per day) for each current drinker, which was drawn from a gamma distribution, which has been shown to approximate alcohol use self-reports from surveys [30, 31] .
  • Lastly, HED status was determined for each current drinker based on the data from step 1, again using binomial distributions.

Step 3: Applying effects of SBIRT

  • In order to apply the effects of SBIRT, the following four conditions had to be fulfilled: Persons had to: attend PHC; be screened for alcohol use; drink riskily; and receive a BI (for medium risk drinkers) or RT (for high-risk drinkers).
  • In the following, each consecutive conditional step is described in detail.
  • Based on these prevalence estimates, binomial distributions were used to determine whether a person had at least one PHC visit in the current year.
  • In addition to manipulating the drinking levels for positively screened persons receiving BI or RT, the HED status was also changed based on effect sizes from the same metaanalysis (see Table 1 for effect sizes).

Step 4: Accounting for secular changes and attenuating intervention effects

  • Step 3, i.e., the application of SBIRT effects, was repeated for each year.
  • Prior to applying the effects in each year, the authors accounted for a) attenuating intervention effects from previous years, and b) secular changes in APC and drinking status prevalence.
  • First, the authors assumed that intervention effects on drinking levels remained stable for a period of four years (according to [25] ), attenuate thereafter, and nullify after ten years (according to [26] , linearly imputed for all years five to ten).
  • For drinkers giving up HED following BI or RT, the authors assumed that the chance to re-engage in HED was 50% chance starting from the second year post intervention.
  • Second, the authors corrected drinking levels among drinkers and drinking status to match the observed trajectories in the input data.

Sensitivity analysis

  • Keeping all other parameters constant, the authors tested the impact of the attenuation of intervention effects over time.
  • In an additional sensitivity analysis, the authors assumed that any intervention effect diminishes three years post intervention.

Reporting the simulation findings

  • The outcomes of interest were drinking levels and prevalence of HED, which are the two alcohol exposure variables known to be most impacted by BI and RT delivered in PHC settings.
  • All findings are reported against the baseline scenario for the final year 2018, thus describing the cumulative effects over a ten-year period.
  • The complete R code including input data is appended to this paper to allow for complete reproducibility and adjustment of parameters to other settings (see S1 file).
  • As input data for the simulation, the authors obtained aggregated and fully anomized secondary data from previous surveys, which have undergone formal ethical reviews (for details, see [21, 23] ).

Alcohol exposure in Germany in the baseline scenario

  • Between 2009 and 2018, alcohol consumption hardly changed in Germany.
  • The green line was taken from the scenario without any screening activity, thus, the drinking level follows the observed trend of drinking levels in this population, as specified in the input data.
  • The blue line was taken from the baseline scenario, thus, at a screening rate of 2.9%.

Estimated coverage of SBIRT

  • Across the ten-year period, every 40 th adult (2.4%, 95% CI: 1.8% to 3.1%) was estimated to have benefitted from an intervention, i.e., BI for medium risk and RT for high-risk drinkers, following alcohol screening in PHC in the baseline scenario.
  • The screening and intervention rates achieved by end of the ten-year period are illustrated in Fig 3 .

Impact on APC and HED

  • In Tables 2 and 3 , the simulation results are presented for two outcomes of interest, the mean daily drinking levels and the prevalence of HED in the adult population.
  • Presented are relative changes of mean drinking levels to the as-is-scenario, with a screening rate of 2.9%.
  • Bold results indicate confidence intervals not overlapping with 0, indicating significant differences to the baseline scenario.
  • Significant reductions of drinking levels could have been achieved for five out of twelve subgroups if one out of two PHC patients were screened for their alcohol use: 15 to 34 year olds with low and middle education levels, 35 to 49 year olds with high education levels, and 65 to 99 year olds with low and high education levels.

Sensitivity analyses

  • In sensitivity analyses, the authors modeled the impact of SBIRT under the more conservative assumption according to which the intervention effects would completely diminish three years post intervention, as compared to the slower attenuation beginning only five years post intervention as implemented in the main analyses.
  • As illustrated in Fig 6 , the scenarios of 0 to 25% screening coverage are robust to the underlying assumption, i.e., changing the assumption would have no significant impact on the estimated drinking levels.

Limitations

  • Before further discussing the findings of this study, the authors need to highlight several limitations.
  • First and foremost, as with any simulation study, the authors rely on assumptions that may not hold true.
  • The authors have attempted to be transparent with all assumptions, reporting all parameters used in the simulation, and performing rigorous sensitivity analyses to test one key assumption.
  • Second, the authors tried to rely mostly on local data, except for effect sizes and attenuation parameters.
  • BI reception was more often reported by socioeconomically disadvantaged drinkers in England [33] , and if similar patterns were present in Germany, this would change the simulation findings accordingly.

Comparison with other simulation studies

  • Several other simulations have quantified the effects of scaling up SBIRT (for an overview, see [16] ), however, the authors are only aware of one application for Germany.
  • In a 2015 report, the Organization for Economic Co-operation and Development, the effects of BI were estimated for a screening coverage of 40% and a 30% intervention probability for positive screened patients, with the effects waning within 12 months after receiving the intervention [17].
  • In their simulation, which was performed for a 40-year time period, the prevalence of hazardous/harmful drinking could be reduced by 5%, while their results suggest a reduction in per capita consumption by 12% in the most comparable scenario of a 50% screening rate over a period of 10 years.
  • The proposed simulation methodology can be extended as well to address health economic issues, including costeffectiveness analyses.
  • In the UK, for example, an assessment of 1.8 million patient records in 2018 found that 48.8% of adult patients had a measure of alcohol consumption recorded during the previous five years [42] .

Implications for alcohol policy in Germany

  • The simulation results suggest that the current coverage of alcohol screening hardly matters for population alcohol exposure in Germany.
  • The authors show that the large-scale delivery of SBIRT in German PHC settings could be a viable measure to accelerate the ongoing trend.
  • In a comparative survey, nearly half of German general practitioners did not consider alcohol as an important risk factor for hypertension, in contrast to a share of 15% among respondents from France, Italy, Spain, and the UK [45] (for evidence on alcohol use and hypertension, see [46] ).
  • While further efforts are needed to increase SBIRT delivery in German PHC settings in the long run, e.g., by financial reimbursement of alcohol management activities [50] , alternatives may be required to reduce alcohol consumption and attributable burden in the short-term.
  • Evidence from Lithuania and Great Britain, for example, demonstrates the impact that policies targeting alcohol prices can have in reducing consumption and harm [54] [55] [56] [57] .

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Content maybe subject to copyright    Report

Full title: Can alcohol consumption in Germany be reduced by alcohol screening, brief 1
intervention and referral to treatment in primary health care? Results of a simulation study 2
Short title: Reducing alcohol consumption through screening, brief intervention and referral to 3
treatment in Germany 4
5
Jakob Manthey*
1,2,3
, Adriana Solovei
4
, Peter Anderson
5,6
, Sinclair Carr
2
, Jürgen Rehm
2,7,8,9,10
6
7
1
Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Chemnitzer Str. 8
46, 01187 Dresden, Germany 9
2
Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, 10
University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, 20246 Hamburg, Germany 11
3
Department of Psychiatry, Medical Faculty, University of Leipzig, Semmelweisstraße 10, 04103 12
Leipzig, Germany 13
4
Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht 14
University, P. Debyeplein 1, Maastricht, The Netherlands 15
5
Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, 16
Newcastle upon Tyne NE2 4AX, UK 17
6
CAPHRI Care and Public Health Research Institute, Maastricht University, POB 616, 6200 MD, 18
Maastricht, The Netherlands 19
7
Institute for Mental Health Policy Research & Campbell Family Mental Health Research Institute, 20
Centre for Addiction and Mental Health, 33 Ursula Franklin Street, Toronto, Ontario, Canada, M5S 2S1 21
8
Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 1P8, 22
Canada 23
9
Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, 24
Canada, M5T 1R8 25
10
Department of International Health Projects, Institute for Leadership and Health Management, I.M. 26
Sechenov First Moscow State Medical University, Trubetskaya str., 8, b. 2, 119992, Moscow, Russian 27
Federation 28
29
* Corresponding author: jakob.manthey@tu-dresden.de
30
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 20, 2021. ; https://doi.org/10.1101/2021.05.18.21257405doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
2
Abstract 31
Background 32
Screening, brief intervention and referral to treatment (SBIRT) is a programme to reduce 33
alcohol consumption for drinkers with high alcohol consumption levels. Only 2.9% of patients in 34
primary health care (PHC) are screened for their alcohol use in Germany, despite high levels of 35
alcohol consumption and attributable harm. We developed an open-access simulation model to 36
estimate the impact of higher SBIRT delivery rates in German PHC settings on population-level 37
alcohol consumption. 38
Methods and findings 39
A hypothetical population of drinkers and non-drinkers was simulated by sex, age, and 40
educational status for the year 2009 based on survey and sales data. Risky drinking persons 41
receiving BI or RT were sampled from this population based on screening coverage and other 42
parameters. Running the simulation model for a ten-year period, drinking levels and heavy 43
episodic drinking (HED) status were changed based on effect sizes from meta-analyses. 44
In the baseline scenario of 2.9% screening coverage, 2.4% of the adult German 45
population received a subsequent intervention between 2009 and 2018. If every second PHC 46
patient would have been screened for alcohol use, 21% of adult residents in Germany would 47
have received BI or RT by the end of the ten-year simulation period. In this scenario, population-48
level alcohol consumption would be 12% lower than it was in 2018, without any impact on HED 49
prevalence. Screening coverage rates below 10% were not found to have a measurable effect on 50
drinking levels. 51
Conclusions 52
Large-scale implementation of SBIRT in PHC settings can yield substantial reductions of 53
alcohol consumption in Germany. As high screening coverage rates may only be achievable in 54
the long run, other effective alcohol policies are required to achieve short-term reduction of 55
alcohol use and attributable harm in Germany. There is large potential to apply this open-access 56
simulation model to other settings and for other alcohol interventions. 57
Keywords: 58
Alcohol use, drinking, screening, brief intervention, referral to treatment, primary health 59
care, statistical modelling, simulation study, population distribution, SBIRT
60
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 20, 2021. ; https://doi.org/10.1101/2021.05.18.21257405doi: medRxiv preprint
3
Introduction 61
Globally, alcohol use is a major risk factor for the burden of mortality and disease [1, 2]. 62
Various initiatives have been set by the World Health Organization (WHO) and the United 63
Nations has set objectives to reduce this burden [3]. Among five high-impact and cost-effective 64
strategies to reduce alcohol use and the resulting burden of disease, the WHO recommends 65
facilitating access to screening and brief interventions (SBI), and treatment [4-6]. 66
Screening for alcohol use, brief intervention (if the alcohol use patterns exceed a certain 67
threshold; BI), and referral to specialized treatment (RT; full acronym: SBIRT) is an evidence-68
based practice used to identify, reduce, and prevent risky alcohol and other drug use and 69
attributable harm (for an introduction, see [7, 8]; for overviews, see [9, 10]). 70
In Germany, application of SBIRT is recommended by the ‘Guidelines on Screening, 71
Diagnosis and Treatment of Alcohol Use Disorders’ [11], however, survey data from the federal 72
state of Bremen suggest that only 2.9% of patients were screened by their primary health care 73
(PHC) providers in 2016 [12]. Given the persistently high prevalence of alcohol use disorders 74
(2018: men: 9.2%; women: 3.6%, [13]), alcohol per capita consumption (APC; recorded sales in 75
2018: 10.8 litres, [14]), and alcohol-attributable mortality (2016: 45,000 or 5% of all deaths, 76
[15]) in Germany, strategies to curb consumption and adverse consequences are urgently 77
required and SBIRT presents a viable option. 78
In a 2014 systematic review, 22 studies have been identified estimating the cost-79
effectiveness of SBI programmes, none of which was performed for Germany [16]. The only 80
application of a simulation model to quantify the effects of SBI in Germany known to the authors 81
was carried out as part of a report issued by the Organization for Economic Co-operation and 82
Development [17]. While the report found the potential of SBI to be sizeable, the results cannot 83
be easily reproduced or the method extended, as the underlying programme was not published. 84
In fact, none of the 22 studies identified in the 2014 review disclosed their simulation 85
programmes [16]. Further, the two perhaps most common and internationally applied simulation 86
programmes do not disclose their source code to the public (for applications of the programs, see 87
[18] and [19]), making it impossible for other researchers to apply or adapt the programme on 88
their own. 89
In this contribution, we develop an open-access simulation model which serves to 90
estimate the impact on increased SBIRT activities in PHC settings on population drinking 91
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 20, 2021. ; https://doi.org/10.1101/2021.05.18.21257405doi: medRxiv preprint
4
patterns and levels. We first give an extensive description of the simulation model and then 92
present results of an application for Germany, testing how alcohol consumption would have 93
changed if more patients would have been screened for their alcohol use in PHC settings. 94
95
Materials and methods 96
97
Fig 1. Flow-chart of simulation procedure. Round shapes represent simulation 98
parameters; rectangular boxes represent the sample selected based on specified parameters; the 99
loop repeats every year, for a period of 10 years. 100
101
The methods employed can be summarized in four steps: 1) A complete time series of 102
alcohol data, more specifically of drinking status and drinking levels, stratified by sex, age, and 103
educational status, was obtained by combining survey and sales data for the years 2009 to 2018; 104
2) A hypothetical population for the year 2009 was drawn, for which drinking status, as well as 105
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 20, 2021. ; https://doi.org/10.1101/2021.05.18.21257405doi: medRxiv preprint
5
drinking levels, were assigned based on data from the first step. 3) For risky drinking persons 106
(definition see Table 1) who were identified by their treating general practitioners through 107
alcohol screening in that year, effects of BI and RT were applied to change drinking levels and 108
patterns. 4) We continued with step 3 in the next year but prior to applying effects from BI and 109
RT, we accounted for: a) attenuating effects of BI and RT over time; and, b) secular changes in 110
prevalence of any drinking and heavy episodic drinking (HED). The simulation procedure is 111
outlined in Fig 1 and all simulation parameters are summarized in Table 1. 112
113
Table 1. Description and sources of simulation parameters 114
Type of
parameter
Description of parameter Source
APC
Recorded APC for all years 2009 to 2018 obtained from [20]
Drinking
status
Prevalence of drinking status at base year, stratified by sex, age group,
and educational level
obtained from [13,
21]
Risky
drinking
Cutoffs to define low, medium and high risk drinking based gram pure
alcohol intake per day (women: 21g and 41g; men: 41g and 61g)
obtained from [22]
PHC access
Probability for PHC visits, stratified by sex, age group, educational
level, and drinking level
calculated from
[23]
Screening
probability
Probability of screening among PHC patients: baseline (2.9%) but
varied in alternative scenarios (0%, 10%, 25%, 50%, 75%)
baseline obtained
from [12]
Intervention
probability
Probability of BI and RT among positively screened patients: 50% obtained from [12]
Effect size
of brief
intervention
The proportional reduction of a) daily drinking levels (women: -15.8%,
-31.1 to -1.1%; men: -12.0%, -18.6 to -5.7%) and b) risk reduction of
HED (risk difference: -0.07, -0.12 to -0.02)
a) recalculated and
b) obtained from a
meta-analysis [24].
Effect size
of referral
to treatment
Effect size of RT, assumed to be the same as for BI
Attenuation
of effects
The attenuation of intervention effects, assuming that BI effects to
remain stable for a period of four years and to attenuate thereafter and
reach 0 after ten years (linearly imputed for all years five to ten)
according to [25]
and [26]
APC = pure alcohol per capita consumption; BI = Brief Intervention; HED = Heavy 115
Episodic Drinking; PHC = Primary Health Care; RT = Referral to Treatment 116
117
118
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 20, 2021. ; https://doi.org/10.1101/2021.05.18.21257405doi: medRxiv preprint
Citations
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Understanding the Association between Alcohol Stigma and Alcohol Consumption within Europe: A Cross-Sectional Exploratory Study

[...]

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Improving alcohol health literacy and reducing alcohol consumption: recommendations for Germany

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Jakob Manthey, Daša Kokole, Steffi G. Riedel-Heller, Gill Rowlands, Ingo Schäfer, Georg Schomerus, Renate Soellner, Carolin Kilian 
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01 Jan 2023-Global Public Health
TL;DR: In this article , the authors identify the country and policy-related factors potentially explaining the country differences in outcomes of an intervention focused on improving detection and management of heavy alcohol use in primary care in Colombia, Mexico and Peru.
Abstract: Researchers and practitioners recognise the importance of context when implementing healthcare interventions, but the influence of wider environment is rarely mapped. This paper identifies the country and policy-related factors potentially explaining the country differences in outcomes of an intervention focused on improving detection and management of heavy alcohol use in primary care in Colombia, Mexico and Peru. Qualitative data obtained through interviews, logbooks and document analysis are used to explain quantitative data on number of alcohol screenings and screening providers in each of the countries. Existing alcohol screening standards in Mexico, and policy prioritisation of primary care and consideration of alcohol as a public health issue in Colombia and Mexico positively contributed to the outcome, while the COVID-19 pandemic had a negative impact. In Peru, the context was unsupportive due to a combination of: political instability amongst regional health authorities; lack of focus on strengthening primary care due to the expansion of community mental health centres; alcohol considered as an addiction rather than a public health issue; and the impact of COVID-19 on healthcare. We found that wider environment-related factors interacted with the intervention implemented and can help explain country differences in outcomes.
Journal Article•DOI•
Improving alcohol management in primary health care in Mexico: A return-on-investment analysis.

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Adriana Solovei, Pol Rovira, Peter J. Anderson, Eva Jané-Llopis, Guillermina Natera Rey, Miriam Castillo Arroyo, Perla Medina, Liesbeth Mercken, Jürgen Rehm, Hein de Vries, Jakob Manthey 
16 Jan 2023-Drug and Alcohol Review
TL;DR: In this article , the authors estimate the return-on-investment of implementing a brief advice and referral to treatment (SBIRT) program in Mexican primary health-care settings and show that scaling up a SBIRT program in Mexico over a 10-year period would lead to positive return on investment values ranging between 21% and 110% in scenario 4 (confidence interval -8.6%, 79.5%) and 110%.
Abstract: INTRODUCTION Alcohol screening, brief advice and referral to treatment (SBIRT) in primary health care is an effective strategy to decrease alcohol consumption at population level. However, there is relatively scarce evidence regarding its economic returns in non-high-income countries. The current paper aims to estimate the return-on-investment of implementing a SBIRT program in Mexican primary health-care settings. METHODS Empirical data was collected in a quasi-experimental study, from 17 primary health-care centres in Mexico City regarding alcohol screening delivered by 145 health-care providers. This data was combined with data from a simulation study for a period of 10 years (2008 to 2017). Economic investments were calculated from a public sector health-care perspective as clinical consultation costs (salary and material costs) and program costs (set-up, adaptation, implementation strategies). Economic return was calculated as monetary gains in the public sector health-care, estimated via simulated reductions in alcohol consumption, dependent on population coverage of alcohol interventions delivered to primary health-care patients. RESULTS Results showed that scaling up a SBIRT program in Mexico over a 10-year period would lead to positive return-on-investment values ranging between 21% in scenario 4 (confidence interval -8.6%, 79.5%) and 110% in scenario 5 (confidence interval 51.5%, 239.8%). Moreover, over the 10-year period, up to 16,000 alcohol-related deaths could be avoided as a result of implementing the program. DISCUSSION AND CONCLUSIONS SBIRT implemented at national level in Mexico may lead to substantial financial gains from a public sector health-care perspective.
References
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Journal Article•DOI•
Effectiveness of brief alcohol interventions in primary care populations

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Eileen Kaner1, Fiona Beyer1, Colin Muirhead1, Fiona Campbell2, Elizabeth D Pienaar3, Nicolas Bertholet4, Jean B. Daeppen4, John B. Saunders5, Bernard Burnand4 •
Newcastle University1, University of Sheffield2, South African Medical Research Council3, University of Lausanne4, Royal Brisbane and Women's Hospital5
18 Apr 2007-Cochrane Database of Systematic Reviews
TL;DR: Brief interventions consistently produced reductions in alcohol consumption, and the effect was clear in men at one year of follow up, but unproven in women.
Abstract: 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

1,226 citations

Journal Article•DOI•
Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis.

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Michael F. Fleming1, Marlon P. Mundt1, Michael T. French1, Linda Baier Manwell1, Ellyn A. Stauffacher1, Kristen L. Barry1 •
University of Wisconsin-Madison1
01 Jan 2002-Alcoholism: Clinical and Experimental Research
TL;DR: The long-term follow-up of Project TrEAT provides the first direct evidence that brief physician advice is associated with sustained reductions in alcohol use, health care utilization, motor vehicle events, and associated costs.
Abstract: Background: This report describes the 48-month efficacy and benefit-cost analysis of Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled trial of brief physician advice for the treatment of problem drinking. Methods: Four hundred eighty-two men and 292 women, ages 18–65, were randomly assigned to a control (n= 382) or intervention (n= 392) group. The intervention consisted of two physician visits and two nurse follow-up phone calls. Intervention components included a review of normative drinking, patient-specific alcohol effects, a worksheet on drinking cues, drinking diary cards, and a drinking agreement in the form of a prescription. Results: Subjects in the treatment group exhibited significant reductions (p < 0.01) in 7-day alcohol use, number of binge drinking episodes, and frequency of excessive drinking as compared with the control group. The effect occurred within 6 months of the intervention and was maintained over the 48-month follow-up period. The treatment sample also experienced fewer days of hospitalization (p= 0.05) and fewer emergency department visits (p= 0.08). Seven deaths occurred in the control group and three in the treatment group. The benefit-cost analysis suggests a $43,000 reduction in future health care costs for every $10,000 invested in early intervention. The benefit-cost ratio increases when including the societal benefits of fewer motor vehicle events and crimes. Conclusions: The long-term follow-up of Project TrEAT provides the first direct evidence that brief physician advice is associated with sustained reductions in alcohol use, health care utilization, motor vehicle events, and associated costs. The report suggests that a patient's personal physician can successfully treat alcohol problems and endorses the implementation of alcohol screening and brief intervention in the US health care system.

530 citations

Brief intervention for hazardous and harmful drinking: a manual for use in primary care.

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Thomas F. Babor, John C Higgins-Biddle
01 Jan 2001
TL;DR: This manual is written to help primary health care workers to deal with persons whose alcohol consumption has become hazardous or harmful to their health.
Abstract: This manual is written to help primary health care workers - physicians, nurses, community health workers, and others - to deal with persons whose alcohol consumption has become hazardous or harmful to their health.

469 citations

Journal Article•DOI•
Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study

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Jakob Manthey1, Kevin D. Shield2, Kevin D. Shield3, Margaret Rylett3, Omer S. M. Hasan2, Omer S. M. Hasan3, Charlotte Probst3, Jürgen Rehm •
Dresden University of Technology1, University of Toronto2, Centre for Addiction and Mental Health3
22 Jun 2019-The Lancet
TL;DR: Based on these data, global goals for reducing the harmful use of alcohol are unlikely to be achieved, and known effective and cost-effective policy measures should be implemented to reduce alcohol exposure.

436 citations

Journal Article•DOI•
Alcohol use disorders

[...]

André F. Carvalho1, Markus Heilig2, Augusto Pérez, Charlotte Probst1, Jürgen Rehm •
Centre for Addiction and Mental Health1, Linköping University2
31 Aug 2019-The Lancet
TL;DR: Clinical interventions for alcohol use disorders should be embedded in a supportive environment, which can be bolstered by the creation of alcohol control policies aimed at reducing the overall level of consumption.

272 citations

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Frequently Asked Questions (18)
Q1. What are the contributions in this paper?

Results of a simulation study 2 Short title: Reducing alcohol consumption through screening, brief intervention and referral to 3 treatment in Germany 4 5 Jakob Manthey *, Adriana Solovei, Peter Anderson, Sinclair Carr, Jürgen Rehm 6 7 1 Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Chemnitzer Str. 8 46, 01187 Dresden, Germany 9 2 Center for Interdisciplinary Addiction Research ( ZIS ), Department of Psychiatry and Psychotherapy, 10 University Medical Center Hamburg-Eppendorf ( UKE ), Martinistraße 52, 20246 Hamburg, Germany 11 3 Department of Psychiatry, Medical Faculty, University of Leipzig, Semmelweisstraße 10, 04103 12 Leipzig, Germany 13 4 Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht 14 University, P. Debyeplein 1, Maastricht, The Netherlands 15 5 Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, 16 Newcastle upon Tyne NE2 4AX, UK 17 6 CAPHRI Care and Public Health Research Institute, Maastricht University, POB 616, 6200 MD, 18 Maastricht, The Netherlands 19 7 Institute for Mental Health Policy Research & Campbell Family Mental Health Research Institute, 20 Centre for Addiction and Mental Health, 33 Ursula Franklin Street, Toronto, Ontario, Canada, M5S 2S1 21 8 Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 1P8, 22 Canada 23 9 Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, 24 Canada, M5T 1R8 25 10 Department of International Health Projects, Institute for Leadership and Health Management, I. M. 26 Sechenov First Moscow State Medical University, Trubetskaya str., 8, b. 2, 119992, Moscow, Russian 27 Federation 28 29 * Corresponding author: jakob. It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 

In 2018, 230 73.8% of drinkers were estimated to have low risk drinking levels, while medium and high-risk 231 drinking was present among 11.9% and 14.3% of drinkers. 

in integrated health-care systems where alcohol measurement is mandated and built into the electronic medical record system, as it is in the US Veterans Health Administration system, coverage can be as high as 93% [43]. 

In the UK, for example, an assessment of 1.8 million patient records in 2018 found that 48.8% of adult patients had a measure of alcohol consumption recorded during the previous five years [42]. 

If combined with health outcomes, e.g. by using the open-access programme InterMAHP [38], their simulation model can be readily adapted to perform health economic studies, such as cost-effectiveness analyses. 

If every second PHC 46 patient would have been screened for alcohol use, 21% of adult residents in Germany would 47 have received BI or RT by the end of the ten-year simulation period. 

70 In Germany, application of SBIRT is recommended by the ‘Guidelines on Screening, 71 Diagnosis and Treatment of Alcohol Use Disorders’ [11], however, survey data from the federal 72 state of Bremen suggest that only 2.9% of patients were screened by their primary health care 73 (PHC) providers in 2016 [12]. 

In sensitivity analyses, the authors modeled the impact of SBIRT under the more conservativeassumption according to which the intervention effects would completely diminish three years post intervention, as compared to the slower attenuation beginning only five years post intervention as implemented in the main analyses. 

If alcohol use was assessed in every fourth patient, reductions in drinking levels among 280 men and the youngest age groups could be achieved. 

A large-scale implementation of SBIRT in Germany could only be achieved in the more distant future, thus, other alcohol policy options should be considered as well to achieve short-term reductions in alcohol consumption. 

The only 80 application of a simulation model to quantify the effects of SBI in Germany known to the authors 81 was carried out as part of a report issued by the Organization for Economic Co-operation and 82 Development [17]. 

the authors determined daily drinking levels (in 152 grams pure alcohol per day) for each current drinker, which was drawn from a gamma 153 distribution, which has been shown to approximate alcohol use self-reports from surveys [30, 154 31]. 

258 Across the ten-year period, every 40th adult (2.4%, 95% CI: 1.8% to 3.1%) was estimated 259 to have benefitted from an intervention, i.e., BI for medium risk and RT for high-risk drinkers, 260 following alcohol screening in PHC in the baseline scenario. 

44 In the baseline scenario of 2.9% screening coverage, 2.4% of the adult German 45 population received a subsequent intervention between 2009 and 2018. 

Their findings suggest that screening up to one tenth of patients per year would not have significantly changed how alcohol consumption has developed in Germany in this time period. 

For drinkers giving up HED 194 following BI or RT, the authors assumed that the chance to re-engage in HED was 50% chance starting 195 from the second year post intervention. 

While further efforts are needed to increase SBIRT delivery in German PHC settings inthe long run, e.g., by financial reimbursement of alcohol management activities [50], alternatives may be required to reduce alcohol consumption and attributable burden in the short-term. 

in the scenarios of 50% and 75% screening coverage, the more conservative assumption would result in APC at the end of the ten-year simulation period to be, respectively, 6.1% (1.5 to 11.4%) and 6.9% (2.5 to 10.4%) higher.