Management of substance abuse

Screening and brief intervention for alcohol problems in primary health care

Alcohol/UK

BACKGROUND

There are many forms of excessive drinking that cause substantial risk or harm to the individual. They include high level drinking each day, repeated episodes of drinking to intoxication, drinking that is actually causing physical or mental harm, and drinking that has resulted in the person becoming dependent on alcohol. Excessive drinking causes illness and distress to the drinker and his or her family and friends. It is a major cause of breakdown in relationships, trauma, hospitalization, prolonged disability and early death. Alcohol-related problems represent an immense economic loss to many communities around the world.

In 1980, a WHO expert committee stressed the need for efficient methods to identify persons with harmful and hazardous alcohol consumption before health and social consequences become pronounced. There was an urgent call for the development of strategies that could be applied in primary health care settings with a minimum of time and resources. Within this context, the WHO Collaborative Project on Identification and Treatment of Persons with Harmful Alcohol Consumption was initiated in 1982 to develop a scientific basis for screening and brief interventions in primary care settings. Phase I of the project linked six collaborating centers representing a broad variety of cultural groups in developing a simple instrument to screen for persons at high risk of alcohol problems in both developing and developed countries. The result of this phase was the introduction of the Alcohol Use Disorders Identification Test (AUDIT). Phase II of the project was a cross-cultural randomized controlled trial to test the usefulness of alcohol screening when it is linked to brief intervention.

Screening for alcohol use: why AUDIT?

The AUDIT was developed as a simple method of screening for excessive drinking and to assist in brief assessment. It can help identify excessive drinking as the cause of the presenting illness. It provides a framework for intervention to help risky drinkers reduce or cease alcohol consumption and thereby avoid the harmful consequences of their drinking. The AUDIT also helps to identify alcohol dependence and some specific consequences of harmful drinking. Of utmost importance for screening is the fact that people who are not dependent on alcohol may stop or reduce their alcohol consumption with appropriate assistance and effort. The manual is particularly designed for health care practitioners and a range of health settings, but with suitable instructions it can be self-administered or used by non-health professionals.

Screening for alcohol consumption among patients in primary care carries many potential benefits. It provides an opportunity to educate patients about low-risk consumption levels and the risks of excessive alcohol use. Information about the amount and frequency of alcohol consumption may inform the diagnosis of the patient's presenting condition, and it may alert clinicians to the need to advise patients whose alcohol consumption might adversely affect their use of medications and otehr aspects of their treatment. Screening also offers the opportunity for practitioners to take preventative measures that have proven effective in reducing alcohol-related risks.

Development and validation of the AUDIT

The AUDIT was developed and evaluated over a period of two decades, and it has been found to provide an accurate measure of risk across gender, age and cultures. As the first screening test designed specifically for use in primary care settings, the AUDIT has the following advantages:

  • Cross-national standardization: the AUDIT was validated on primary health care patients in six countries. It is the only screening test specifically designed for international use;
  • Identifies hazardous and harmful alcohol use, as well as possible dependence;
  • Brief, rapid and flexible;
  • Designed for primary health care workers;
  • Consistent with ICD-10 definitions of alcohol dependence and harmful alcohol use;
  • Focuses on recent alcohol use.

BRIEF INTERVENTION

Brief interventions are those practices that aim to identify a real or potential alcohol problem and motivate an individual to do something about it. Brief interventions have become increasingly valuable in the management of individuals with alcohol-related problems. During the past 20 years, there have been numerous randomized trials of brief interventions in a variety of health care settings. Studies have been conducted in Australia, Bulgaria, Mexico, the United Kingdom, Norway, Sweden, the United States and many other countries. Results from these studies show that there is clear evidence that well-designed brief intervention strategies are effective, low-cost and easy to administer.

Because research has shown that brief interventions are low in cost and have proven to be effective across the spectrum of alcohol problems, health workers and policy-makers have increasingly focused on them as tools to fill the gap between the primary prevention efforts and more intensive treatment for persons with serious alcohol use disorders. It is worth noting that brief interventions are not designed to treat persons with alcohol dependence, which generally requires greater expertise and more intensive clinical management. However, they might serve well as as initial treatmentfor severely dependent patients seeking extended treatment.

Alongside with the companion publication on the AUDIT, WHO has also produced a manual to aid primary health care workers in administering brief interventions to persons whose alcohol consumption has become hazardous or harmful to their health. Together, these manuals describe a comprehensive approach to alcohol screening and brief intervention (SBI) that is designed to improve the health of the population and patient groups as well as individuals.

Phase III of the AUDIT project

The rationalization of Phase III component of the brief interventions project stemmed from the realization and desire to promote the incoroporation of brief alcohol interventions within primary care. Fourteen countries from Europe, the Asia Pacific region and North America were involved, and a representative sample of medical practitioners engaged in primary health care was obtained from each participating country. Participants were asked about their current practices in preventive medicine, training and knowledge in preventive medicine, self-efficacy, role acceptance and perceived barriers to delivering preventive medicine.

Phase IV of the AUDIT project

The rationale for the Phase IV project was to oversee the development and application of strategies for the widespread, routine and enduring implementation of SBI in the primary health care systems of the 13 participating countries. More specific information can be found in the Phase IV website. In the Phase IV project countries adopt different strategies to meet these objectives in line with local conditions and needs. In this way, the implementation of strategies to promote the uptake and sustainability of brief interventions is flexible in nature.

The central framework of the strategy adopted in the Phase IV work consists of four components:

  • Customization of materials and services appropriate for local conditions;
  • Reframing the understanding of alcohol issues by the community and by practitioners;
  • Establishing a lead organization and building a strategic alliance among organizations and individuals interested in widespread and routine implementation on SBI;
  • Carrying out a demonstration project to demonstrate that routine implementation of SBI in primary health care is feasible and has wider health and economic benefits for the community.

The phase IV project has the following features:

  • Evaluation of the extent to which the study aims have been achieved, especially the overall impact of the study on the country-wide implementation of SBI;
  • Economic evaluation, e.g. cost of implementing SBI per patient, health and other economic benefits for primary health care and for the wider community, possible cost-offsets, etc. It was noted that presenting potential economic benefits or savings to health care systems could be a powerful political ammunition in garnering support for the project;
  • Action research – an iterative process which aims to impact real-world primary health care service delivery as well as increase knowledge;
  • Use of qualitative and quantitative methods.

Dissemination of brief interventions for alcohol problems in primary health care: a strategy for developing countries

Recognising that screening and brief intervention (SBI) for alcohol-related problems in primary health care can be an effective and efficient way to reduce alcohol consumption by hazardous and risky drinkers, a WHO meeting was held to begin the task of disseminating SBI to the rest of the developing world. Two countries were selected for this project: Brazil and South Africa. A group of international experts, consultants and representatives from the two country sites convened in Alicante, Spain from 24-27 September 2002 to begin discussions on the matter.

The scope and purpose of the meeting included the following:

  • To understand the current responses to alcohol problems in sites in Brazil and South Africa and the organization of their health system;
  • To review experiences and results with the dissemination of brief interventions in developed countries and other settings;
  • To delineate steps needed to implement and widely disseminate brief interventions in developing countries;
  • To discuss training needs and materials available, or to be developed, for supporting the project in each of the sites;
  • To discuss mechanisms for evaluating plans in each site;
  • To develop a common framework for the dissemination of brief interventions in developing country settings.

Some long-term objectives or expectations that would hopefully transpire from this meeting include making screening and brief intervention part of health care systems; helping people with potential alcohol problems recognize the value of early intervention; reducing the stigma associated with alcohol problems; developing local expertise for implementing SBI; raising the profile of alcohol problems in health practice, policy making and the media; making it easy and meaningful for people to seek help for alcohol problems; and mobilizing partners, e.g. NGOs and religious groups to work on alcohol problems collaboratively.

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