Interventions for alcohol and drug problems in outpatient settings: A systematic review

COMPREHENSIVE REVIEW

Interventions for alcohol and drug problems in outpatient settings:A systematic review

JUDITH M. WATSON1, DEBRA FAYTER2, NOREEN MDEGE1, LISA STIRK2,AMANDA J. SOWDEN2 & CHRISTINE GODFREY1

1Department of Health Sciences, University ofYork, York, UK, and 2Centre for Reviews and Dissemination, University ofYork, York, UK

AbstractIssues.Research evidence indicates a high prevalence of substance abuse among patients presenting in general hospital settings.Such misuse of alcohol and illicit drugs has a major impact on population health and on costs to health services and to societyat large.This review aimed to identify the interventions for alcohol or illicit drug misuse problems that have been evaluated forhospital outpatient populations. Approach. Thirteen electronic databases including MEDLINE, EMBASE and PsycInfowere searched for published and unpublished studies in any language up to August 2011. Reference lists of included studies andreviews were also hand-searched.We included randomised and controlled clinical trials of any intervention for adult participantsidentified as having alcohol and/or drug problems presenting to hospital outpatient settings other than addiction or psychiatricunits. Participants could be attending hospital for any reason other than treatment for substance abuse. A narrative synthesiswas conducted. Key Findings. There is some evidence to suggest that interventions based on motivational techniques mightbe effective in treatment of alcohol misuse in oral–maxillofacial clinics but not in general outpatient departments.The evidenceis insufficient to allow any conclusions to be derived on the effectiveness of interventions in the treatment of drug misuse andcombined alcohol–drug misuse in outpatient settings. Conclusions. Further research is needed to investigate interventions foralcohol and drug misuse in outpatient settings.Additionally, problems remain in terms of study quality. Procedures to ensure therigour of a study were often poorly reported. [Watson JM, Fayter D, Mdege N, Stirk L, Sowden AJ, Godfrey C.Interventions for alcohol and drug problems in outpatient settings: A systematic review. Drug Alcohol Rev2013]

Key words: alcohol problem, drug problem, outpatient, treatment.

Background

Alcohol consumption is reported as the world’s thirdlargest risk factor for disease and disability, with almost4% of all deaths worldwide attributed to alcohol [1]. Inaddition, the misuse of illicit drugs accounts for the lossof 11.6 million disability-adjusted life years annuallyworldwide, which is 0.8% of the total burden of disease[2].

Although an increasing awareness of recommendedsafe drinking limits has developed in England, it is

estimated that over 24% of the adult population arehazardous drinkers [3], and alcohol-related hospitaladmissions have risen by 69% from 2002 to 2007/2008,now standing at 863 300 [4]. Likewise, around fourmillion people use illicit drugs each year in the UK, anda total of 42 170 admissions with a primary or second-ary diagnosis of drug misuse were noted in 2008/2009[5].

Health-care professionals across a range of hospitalsettings will regularly encounter patients with substancemisuse problems and may have an opportunity to inter-

Judith M.Watson PhD, Research Fellow, Debra Fayter MSc, Research Fellow, Noreen Mdege MSc, Research Fellow, Lisa Stirk MSc, InformationSpecialist, Amanda J. Sowden PhD, Deputy Director, Christine Godfrey BA, Emeritus Professor. Correspondence to Dr Judith M. Watson,Department of Health Sciences,York Trials Unit, ARRC Building—LG Floor, University ofYork, Heslington,YorkYO10 5DD, UK. Tel: +44 (0)1904 321306; Fax: +44 (0) 1904 321387; E-mail: [email protected]

Received 18 October 2012; accepted for publication 8 February 2013.

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Drug and Alcohol Review (2013)DOI: 10.1111/dar.12037

© 2013 Australasian Professional Society on Alcohol and other Drugs

vene. If a condition is potentially related to misuse ofalcohol and/or illicit drugs, some patients may, on dis-cussion, realise the association between their substancemisuse and their ill-health, potentially providing what isknown as a ‘teachable moment’ [6].

Treating substance misuse can result in substantialcost savings, with recent estimates suggesting that forevery £1 spent on treatment for drug problems, at least£9.50 can be saved in criminal justice and health costs[7]. In 2008, the Department of Health estimated thatthe costs to the health service because of alcohol misusewere in the region of £2.7 billion per year [8].There isgrowing interest and need for early detection of patientswith such substance misuse problems [9].

A number of systematic reviews already exist in thefield of drug and alcohol misuse [10–13]. However,none focus solely on outpatient settings and oftenconsider a single type of intervention (e.g. brief inter-vention). In this review, we were interested in theeffectiveness of any intervention offered in hospital out-patient settings to patients who might not know theyhave an alcohol or drug misuse problem and/or mightnot seek help.

Methods

This review was undertaken according to the principlesrecommended in the Centre for Reviews and Dissemi-nation guidance [14].This includes the production of adetailed protocol, which is available at: http://www.york.ac.uk/healthsciences/trials-unit/arias/links/.

Search strategy

The following electronic databases were searched forcontrolled trials (randomised and non-randomised)published up to August 2011: MEDLINE;C2-SPECTR; CINAHL; Cochrane Central Register ofControlled Trials; Cochrane Database of SystematicReviews; Conference Proceedings Citation Index -Science; DARE; EMBASE; HMIC; HTA Database;NHS Economic Evaluations Database; PsycInfo; andPublic Health Interventions Cost Effectiveness Data-base. Full search strategies for each database searchedare provided in Appendix S1.

The reference lists of included papers were assessedfor additional relevant studies, and ongoing studieswere identified from ClinicalTrials.gov (via websiteat: http://www.clinicaltrials.gov/). Where necessary,authors of ongoing or unpublished studies were con-tacted for further information so as to assess eligibilityfor the review.

Identification of included studies

Two reviewers independently screened all titles andabstracts. The full manuscripts of potentially relevant

studies were retrieved and assessed for relevance inde-pendently by two reviewers according to the inclusioncriteria. Discrepancies were resolved by discussion orby referral to the project team when necessary.

Inclusion criteria

We included studies recruiting participants aged 16 orabove, identified as having an alcohol and/or drugproblem (as per each study’s inclusion criteria) present-ing to an acute hospital outpatient setting for anyreason other than specifically for alcohol or illicit drugmisuse treatment. All levels of severity of alcohol abusewere eligible including severe dependence.We includedrandomised controlled trials (RCT) (individual orcluster) and controlled clinical trials (CCTs). Any typeof intervention was eligible for inclusion and could haveone or more components, pharmacological and non-pharmacological, be delivered to individuals or groupsface to face or using the telephone or other media.Comparator interventions could include no treatment(assessment only without referral), waiting list control,‘usual care’ or other active treatments. Studies wherereferral to specialist services was the purpose wereincluded. Outcomes could include: a measure ofalcohol consumption (e.g. quantity/frequency, percent-age of time abstinent and alcohol questionnaire scores);a measure of drug use (e.g. number of days used anddrug questionnaire scores); biochemical measures ofalcohol use; injury; mortality rates; quality of life meas-ures; numbers seeking specialist treatment for alcohol/drug misuse; criminal offences (e.g. driving whileintoxicated and assault) and motivation/readiness tochange. Published and unpublished studies from anycountry and reported in any language were eligible forinclusion.

Interventions directed primarily at whole hospitalpopulations without screening for alcohol or drug prob-lems and those screening patients solely to ascertainprevalence of substance misuse problems were not eli-gible.We also excluded: studies focusing specifically onparticipants with a dual diagnosis and abuse of pre-scription medications and studies set in specialist psy-chiatric wards/facilities, addiction services or addictiontreatment programmes. Studies focusing specifically onpregnant women were also excluded as we consideredthem to be a separate group and one that has beenadequately reviewed elsewhere [15,16].

Data extraction

Following piloting of a selection of studies to ensureconsistency, data were extracted independently by onereviewer and checked by a second reviewer. Discrepan-cies were resolved by discussion, with involvement of a

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2 J. M. Watson et al.


third reviewer when necessary. Data extracted includedstudy methods, setting, participant characteristics,intervention, comparators, outcomes, outcome meas-ures and results.

Quality assessment

Quality was assessed by one reviewer and independ-ently checked by a second reviewer. Disagreementswere resolved by consensus, and a third reviewer con-sulted if necessary. Items assessed included: presence ofa power calculation, adequacy of randomisation andallocation concealment, appropriate adjustment forcovariates, blinding of outcome assessors, adequacy offollow up (deemed to be a minimum of 12 months) andexplanation of dropouts and use of intention to treatanalysis. Details of attempts to maintain interventionfidelity were recorded (e.g. adequacy of training forthose delivering the intervention, use of checklists,audio or video taping patient interviews, direct obser-vation, etc.).

Methods of analysis

Significant methodological heterogeneity existedamong the studies, predominately regarding the out-comes reported, how they were defined and meas-

ured. Various measures include: number of drinkingdays in the past 30 days; alcohol consumption in thepast 3 months; mean drinks per drinking day; andchange in alcohol consumption at 12 months. Therewere also differences in baseline consumption levelsfor eligibility, the health-care professionals deliveringthe intervention and inclusion/exclusion by gender.Given the diversity of the studies included in thisreview, it was considered that a meta-analysis wasinappropriate. A narrative synthesis was conductedand evidence summaries created incorporating anevaluation of the quality of the evidence. This reviewhas been reported in accordance with the PRISMAstatement [17].

Results

The search identified 3699 potentially relevant refer-ences (Figure 1), which were screened, and 396 wereretrieved for detailed evaluation. Of these, 334 wereexcluded due to not being related to drug or alcoholproblems, not in a general hospital setting, or not anRCT or controlled clinical trial. A further 55 wereexcluded for being conducted in emergency (n = 34)and inpatient settings (n = 21).

Seven were conducted in outpatient settings and arepresented in this paper.

Titles and abstracts screened from

electronic searches n = 3631

Full papers screened

n = 396

Included in full review

n = 7

Excluded

n = 389

(Not drug or alcohol

problems, not an RCT or CCT

participants under 16, not a

general hospital setting;

emergency or inpatient

setting)

Interventions for alcohol

misuse

n = 5

Interventions for drug

misuse

n = 1

Interventions for alcohol

and drug misuse

n = 1

Ide

ntifica

tio

n

Scre

en

ing

E

ligib

ility

In

clu

de

d

Ongoing studies identified

from ClinicalTrials.gov n = 2

Papers identified from

checking reference lists n = 68 Excluded n = 3303

(Duplicates; not relevant)

Figure 1. Flow chart showing the number of potentially relevant references identified during the searches and the number included inthe review.

Outpatient alcohol and drug interventions 3


Description of included studies (Table 1)

Five studies investigated the effectiveness of interven-tions for excessive alcohol use [18–22]; one investigatedinterventions for drug misuse [23]; and one for bothexcessive alcohol and illicit drug use [24]. Three wereconducted in the USA [20,23,24], two in the UK)[18,19], one in the Netherlands [21] and one inSweden [22].

Interventions for alcohol misuse

Five RCTs including a total of 1058 adult participantswere included in the review [18–22]. Study interven-tions were compared with usual care (which may haveincluded advice on alcohol) [19,21]; provision of astandard alcohol information leaflet [18]; assessmentinterview only [20]; and, in one study, no contact for 12months [22]. Results are presented in a narrative syn-thesis. It was hoped to divide the studies according tothe behavioural change techniques used in the interven-tions, following the framework proposed by Abrahamand Michie [25]. However, this was hampered due topoor reporting of intervention content and behaviourchange techniques.

Effectiveness of the evaluated interventions foralcohol misuse

Alcohol consumption. One of the two studies con-ducted in oral and maxillofacial outpatient clinicsfound no statistically significant treatment differencesat 3 months (based on 103 of 195 participants ran-domised) regarding changes in number of drinkingdays or number of standard drinks per drinking day[18]. However, at 12, months there was a statisticallysignificant difference between the treatment groups infavour of the motivational intervention in terms ofchange in drinking days (P = 0.007) and heavy drinkingdays (P = 0.03).This was not the case for the number ofstandard drinks per drinking days (P = 0.2) [18]. In thesecond study, there was a significantly greater reductionin the percentage of hazardous drinkers in the motiva-tional intervention group compared with the controlgroup [19]. Although the number of days abstinent didnot vary significantly between groups, at 12 months,only 27% of the intervention group were drinkingabove the guidelines of 21 units per week [decreasefrom 45/75 (60%) to 16/60]; in the control group, 51%were drinking above the guidelines [decrease from41/76 (54%) to 31/61] [19].There was also a significantinteraction effect for time and treatment for thisoutcome favouring the motivational intervention(F = 3.60, P < 0.029), with significant differencesbetween the treatment groups at both 3 and 12 months

[19]. This pattern was repeated for alcohol consump-tion in a typical week with a significant main effect fortime (F = 4.59, P < 0.011) and significant interactionfor time and treatment (F = 3.30, P < 0.039) [19].

Within the studies conducted in various outpatientclinics, the all-female study comparing assessmentinterview plus brief intervention versus assessmentinterview only found no significant differences betweentreatment groups for all drinking outcomes at 12months [20]. The mean difference in change in drinksper drinking day (adjusted) was -0.06 (-0.3, 0.18)P = 0.63; mean difference in change in percentagedrinking days (adjusted) was 3.0 (-0.1, 6.0) P = 0.07;mean difference in change in number of binge episodes(adjusted) was -2.2 (-4.9, 0.54) P = 0.11; and meandifference in change in number of weeks exceedingsensible drinking limits (adjusted) was 0.27 (-1.2,0.65) P = 0.57. Similarly, the study set in a generalinternal medicine outpatient clinic reported, at a meanfollow-up of 28 weeks, a reduction in alcohol consump-tion over time but no significant differences betweenthe Dutch Motivational Drinkers Check-up (Doorlich-ting, Voorlichting Alcoholgebruik; DVA) and thecontrol, routine hospital care [DVA change 0.81 (2.0);control change 0.84 (2.61) units per day, P = 0.46][21].There were no differences in percentage change ofcarbohydrate-deficient transferrin (appears in serumafter high alcohol intake, where some of the transferrinmolecules appear to lack two to four of their terminaltri-saccharides: hence the name carbohydrate-deficienttransferrin [26]) [DVA change 0.052 (0.32); controlchange 0.051 (0.88), P = 0.69] [21].

Conversely, the study conducted in five different out-patient clinics comparing assessment and frequentfollow-ups and feedback versus no contact [22] found asignificant reduction in the mean amount of alcoholconsumed per week from 179 g (� 106 SD) to 117 g(� 101 SD) (P < 0.005) in the intervention group at 12months but did not report changes in the control group.In the intervention group, gamma glutamyl transfease(a well-established biomarker of excessive alcohol con-sumption and liver dysfunction [27]) values were alsosignificantly reduced from baseline but did not differsignificantly from those of the controls.

Alcohol questionnaire scores. Assessing hazardousdrinking using the Alcohol Use Disorders IdentificationTest questionnaire (AUDIT), Smith et al. [19] foundthat in the intervention group, the percentage of haz-ardous drinkers dropped from 95% at baseline to 58%at 12-month follow-up. The corresponding figures inthe control group were 96% and 81%. The sameauthors found a main effect of time (F = 98.32.P < 0.001) but no effect of intervention in terms ofBrief Alcohol Problem Questionnaire scores [19].



Tab

le1.

Sum

mar

yof

the

stud

ies

cond

ucte

din

outp

atie

ntse

tting

sin

clud

edin

the

revi

ew

Aut

hors

(yea

r)

Alc

ohol

ordr

ugm

isus

e?C

ount

ry,

scre

enin

gse

ttin

gP

arti

cipa

nts:

num

ber

rand

omis

ed(%

mal

e);

mea

nag

e;ba

selin

eda

taIn

terv

enti

onan

dco

ntro

lO

utco

mes

asse

ssed

Goo

dall

etal

.(2

008)

[18]

Alc

ohol

UK

Thr

eeor

alan

dm

axill

ofac

ial

outp

atie

ntcl

inic

s

n=

195

(91%

mal

e);

Med

ian

age

=38

for

wom

en;

28fo

rm

en;

AU

DIT

scor

e8–

40(m

edia

n15

);72

%ha

dbe

enas

saul

ted

Inte

rven

tion

:B

rief

Inte

rven

tion

(mot

ivat

iona

l)de

liver

edby

rese

arch

nurs

e:no

furt

her

deta

ilgi

ven

Con

trol

:S

tand

ard

alco

hol

info

rmat

ion

leafl

et

At

3an

d12

mon

ths:

Num

ber

ofdr

inki

ngda

ysin

the

past

30da

ysN

umbe

rof

abst

inen

tda

ysin

the

past

30da

ysN

umbe

rof

heav

ydr

inki

ngda

ys.

Num

ber

ofst

anda

rddr

inks

/dri

nkin

gda

y.S

mit

het

al.

(200

3)[1

9]A

lcoh

olU

KO

ral

and

max

illof

acia

lsu

rger

yde

part

men

tou

tpat

ient

clin

ic

n=

151

(100

%m

ale)

;M

ean

age

=24

;AU

DIT

>95

.4%

scor

edov

er8;

BA

PQ

—55

.7%

scor

edbe

twee

n2

and

6;A

DD

-SF

—72

.2%

clas

sed

aslo

w-l

evel

depe

nden

ce,

21.2

%m

ediu

m-l

evel

,2.

7%hi

gh-l

evel

;80

%of

inju

ries

wer

eas

saul

tre

late

d

Inte

rven

tion

:M

otiv

atio

nal

Inte

rvie

win

g:du

rati

onan

din

tens

ity

unkn

own,

deliv

ered

bytw

ose

nior

gene

ral

nurs

esC

ontr

ol:

Usu

alca

re

At

3an

d12

mon

ths:

AU

DIT

Bri

efA

lcoh

olP

robl

ems

Que

stio

nnai

re(B

AP

Q)

(five

item

s)S

hort

-For

mA

lcoh

olD

epen

denc

eD

ata

(AD

D-S

F)

90I

drin

kdi

ary

sect

ion—

alco

hol

cons

umpt

ion

inpa

st3

mon

ths

Det

ails

oflif

eev

ents

Cha

nget

al.

(201

1)[2

0]A

lcoh

olU

SA

Out

pati

ent

clin

ics

ata

wom

en’s

hosp

ital

n=

511

(0%

mal

e);

mea

nag

e=

45.1

;m

ean

drin

kpe

rdr

inki

ngda

y=

2.2;

mea

npe

rcen

tage

drin

king

days

=23

;m

ean

num

ber

ofbi

nge

epis

odes

=7.

35;

mea

nw

eeks

>st

anda

rdda

ilylim

its

=3.

8

Inte

rven

tion

:An

asse

ssm

ent

inte

rvie

wan

dB

rief

Inte

rven

tion

(30

min

s)de

liver

edby

phys

icia

nan

din

terv

iew

sat

3,6

&12

mon

ths

Con

trol

:An

asse

ssm

ent

inte

rvie

ww

ith

asi

ngle

12-m

onth

inte

rvie

wto

obta

info

llow

-up

data

At

3,6

and

12m

onth

sfo

rB

rief

Inte

rven

tion

grou

pan

dat

12m

onth

sfo

rco

ntro

lgr

oup:

Mea

ndr

inks

per

drin

king

day

Per

cent

age

drin

king

days

Num

ber

ofbi

nge

epis

odes

(fou

ror

mor

edr

inks

per

occa

sion

)N

umbe

rof

wee

ksex

ceed

ing

Nat

iona

lIn

stit

ute

onA

lcoh

olA

buse

and

Alc

ohol

ism

(NIA

AA

)st

anda

rdda

ilylim

its.

Em

men

etal

.(2

005)

[21]

Alc

ohol

The

Net

herl

ands

Gen

eral

inte

rnal

med

icin

eou

tpat

ient

clin

ic

n=

123

(76%

mal

e);

37%

prob

able

orce

rtai

nal

coho

l-re

late

dm

edic

aldi

agno

sis;

mea

nag

e=

50.0

inin

terv

enti

ongr

oup;

47.9

inco

ntro

lgr

oup

Inte

rven

tion

:B

rief

Mot

ivat

iona

lIn

terv

enti

onan

das

sess

men

t(9

0m

in)

and

feed

back

(60

min

)se

ssio

n1–

2w

eeks

late

rC

ontr

ol:

Usu

alca

re

Fol

low

-up

at23

–36

wee

ks(m

ean

28w

eeks

;S

D=

2.39

,ra

nge

23–3

6):

Sel

f-re

port

edch

ange

inal

coho

lco

nsum

ptio

nas

unit

s/da

yC

hang

ein

carb

ohyd

rate

-defi

cien

ttr

ansf

erri

nfr

omba

selin

eC

hang

ein

read

ines

sto

chan

gedr

inki

ngbe

havi

our

Red

ucti

ons

from

abov

eto

belo

whe

alth

limit

s



Tab

le1.

(Con

tinue

d)

Aut

hors

(yea

r)

Alc

ohol

ordr

ugm

isus

e?C

ount

ry,

scre

enin

gse

ttin

gP

arti

cipa

nts:

num

ber

rand

omis

ed(%

mal

e);

mea

nag

e;ba

selin

eda

taIn

terv

enti

onan

dco

ntro

lO

utco

mes

asse

ssed

Per

sson

&M

agnu

sson

(198

9)[2

2]

Alc

ohol

Sw

eden

Fiv

edi

ffer

ent

outp

atie

ntcl

inic

s

n=

78(7

8%m

ale)

;58

(74%

)de

finit

epr

oble

mdr

inki

ng;

20(2

6%)

prob

able

prob

lem

drin

king

;m

ean

age

not

stat

ed

Inte

rven

tion

:P

hysi

cal

exam

inat

ion

and

clin

ical

asse

ssm

ent.

Mon

thly

follo

w-u

pfo

r12

mon

ths

byhe

alth

prof

essi

onal

sw

here

alco

hol

cons

umpt

ion

and

labo

rato

ryva

lues

wer

edi

scus

sed

and

feed

back

was

give

n.C

ontr

ol:

No

init

ial

cont

act

and

nodi

scus

sion

abou

tal

coho

l

At

12m

onth

s:C

hang

ein

alco

hol

cons

umpt

ion

Sic

knes

sbe

nefit

sV

isit

sto

outp

atie

ntcl

inic

s.H

ospi

tal

adm

issi

ons

Lab

orat

ory

para

met

ers

Ber

nste

inet

al.

(200

5)[2

3]D

rugs

US

AT

hree

outp

atie

ntcl

inic

s(U

rgen

tca

re,

Wom

en’s

Clin

ic,

Hom

eles

sC

linic

)

n=

1175

(70.

6%m

ale)

;46

%w

ere

hom

eles

s;83

%no

tcu

rren

tly

wor

king

;m

ean

age

=37

.8in

inte

rven

tion

grou

p;38

.1in

cont

rol

grou

p

Inte

rven

tion

:M

otiv

atio

nal

Inte

rvie

w(1

0to

45m

in-

aver

age

20m

in)

tailo

red

toin

divi

dual

,ac

tive

refe

rral

san

dw

ritt

enha

nd-o

utan

dde

liver

edby

peer

s(e

xper

ienc

edsu

bsta

nce

abus

eou

trea

chw

orke

rsin

reco

very

).B

oost

erph

one

call

10da

ysla

ter

(5–1

0m

ins)

Con

trol

:Wri

tten

hand

-out

only

At

6m

onth

s:A

bsti

nenc

efr

omco

cain

ean

d/or

hero

inas

mea

sure

dby

radi

oim

mun

oass

ayof

hair

(als

ore

duct

ion

inus

e)C

onta

cts

wit

hsu

bsta

nce

abus

etr

eatm

ent

syst

emA

ddic

tion

Sev

erit

yIn

dex

Gilb

ert

etal

.(2

008)

[24]

Alc

ohol

and

drug

s

US

AF

ive

outp

atie

ntH

IVcl

inic

s

n=

476

(79%

mal

e);

mea

nag

e=

44.1

;18

2(3

9%)

repo

rted

risk

ydr

inki

ng;

200

(42%

)re

port

edill

icit

drug

use

Inte

rven

tion

:T

ailo

red

risk

-red

ucti

onco

unse

lling

from

a‘V

ideo

Doc

tor’

prog

ram

me,

prin

ted

wor

kshe

etan

ddi

scus

sion

wit

hhe

alth

prof

essi

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Health-care utilisation. Persson and Magnusson didnot find a significant difference between groups interms of health-care consultations, and due to the smallnumber, were unable to analyse admissions to hospitalwards [22].

Motivation/readiness to change. Emmen et al. foundthat although in total, 32% of those patients who weredrinking above health limits at follow up did change toa high motivational stage, no statistically significant dif-ferences between the two groups were found (interven-tion group 39.3%, control group 25.0%, P = 0.091)[21].

Interventions for drug misuse

We identified only one study evaluating interventionsfor drug misuse in an outpatient setting [23] wheremotivational interviewing plus a hand-out and a follow-ing booster session was compared with a control (hand-out only). Participants were mostly male (70.6%), andthose undergoing treatment for drug abuse wereexcluded [23].

Effectiveness of the evaluated intervention for drug misuse

Abstinence. Participants who had received the motiva-tional interview, hand-out and booster telephone callwere more likely than the controls to be abstinent at 6months from cocaine [22.3% vs. 16.9%, odds ratio(OR) 1.51; 95% confidence interval (CI) 1.01, 2.24,P = 0.045] and from opiates (40.2% vs. 30.6%, OR1.57; 95% CI 1.00, 2.47, P = 0.050) [23]. Abstinencefrom both drugs did not differ between groups (17.4%vs. 12.8%, OR 1.51; 95% CI 0.98, 2.26, P = 0.052)[23].

Reduction in drug levels and self-reported contact withtreatment services. Although levels of cocaine andheroin measured in hair samples were significantlylower at follow-up for the whole study sample, thedifferences between groups on levels of cocaine merelybordered on significance, and there was no significantdifference for heroin. No differences were seen betweengroups regarding contact with substance abuse treat-ment services at 6 months (39% in intervention group,37% in the control group). For the majority, however,this consisted of detoxification only. In all AddictionSeverity Index subscale scores, both the interventionand control groups improved. On the drug subscale,there was a 49% reduction in the intervention groupand a 46% reduction in the control group (P = 0.06),and on the medical subscale, a 56% reduction in theintervention group and 50% reduction in the controlgroup (P = 0.055) [23].

Interventions for alcohol and drug misuse

Only one study investigating the effectiveness of inter-ventions for both excessive alcohol and illicit drug usein outpatient settings was identified [24]. The studyevaluated a Positive Choice ‘Video Doctor’ intervention;a laptop-based interactive programme with risk-reduction messages based on the principles of Motiva-tional Interviewing [24]. This was followed up by abooster session 3 months after the first session. An‘Educational Worksheet’ was given to the patient withquestions for self-reflection, harm reduction tips andlocal resources. A ‘Cueing Sheet’ allowed the healthprofessional to indicate whether a discussion had takenplace on the various areas. The intervention was tai-lored to participant’s gender, risk profile and readinessto change. The control group did not use the ‘VideoDoctor’ nor receive the Educational Worksheet andCueing Sheet. Instead, after the risk assessment, theyreceived usual care [24].

There was no exclusion criterion for very heavy/dependent drinkers, or dependent drug users and nonespecified for those who had previously received or werecurrently receiving treatment for excessive alcoholand/or illicit drug use [24]. Information was notreported on the proportion of participants who fell intothese categories.

Effectiveness of the evaluated intervention for alcohol anddrug misuse

The authors reported that the intervention group wasstatistically significantly less likely than the usual caregroup to report any ongoing drug use at 3 months(67% vs. 82%, relative risk (RR) 0.81, 95% CI: 0.689,0.957, P = 0.014) and at 6 months (56% vs. 86%, RR0.65, 95% CI: 0.540, 0.785, P < 0.001) [24]. Therewas, however, no statistically significant differentbetween the groups at both those time points on: reduc-tion in total days of any drug use in the previous monthand cessation of risky drinking [24].

Study quality and fidelity (Table 2)

Of the two alcohol trials set in oral and maxillofacialoutpatient settings, the study by Smith et al. [19]appeared to be of better quality than that of Goodallet al. [18]. Although dropouts did occur in both trials,Smith et al. [19] clearly reported dropout reasons(19%), whereas Goodall et al. did not (31%) [18].Goodall et al. also failed to make it clear as to whetherthey had used intention-to-treat analysis.

Of the three alcohol trials set in general outpatientsettings [20–22], only one provided a power calculationto determine sample size [21]. None clearly explained



the methods of randomisation or allocation conceal-ment, nor were any outcome assessors blinded [20–22].Emmen et al. [21] did not conduct adequate follow-up(�12 months), although intention-to-treat analysis wasused and reasons for dropout was explained. Dropoutwas reported by Chang et al. [20] as 4% and 9% in thetrial by Emmen et al. [21].

In the drug study conducted by Bernstein et al., allo-cation concealment was not adequately reported [23].The study only had a 6-month follow-up (dropout of18%) and did not use an intention-to-treat analysis[23]. When reporting their alcohol and drugs study,Gilbert et al. provided the most information [24],although follow-up was only for 6 months and loss tofollow-up at the end of the study was 17.6% [24].

With regard to fidelity, Smith et al. described thetraining given to the interventionists and how they hadmaintained intervention fidelity through supervisionand review of audio-taped intervention sessions [19].Goodall et al. reported only training of interventionists[18]. Both Chang et al. and Emmen et al. reportedmethods used to ensure intervention fidelity (includingtraining staff and reviewing interventions using obser-vations or checklists) [20,21]. Persson and Magnussondid not report any such measures of intervention fidel-ity [22].

In the trial conducted by Bernstein et al., extensiveattempts were made to ensure the integrity and fidelityof the interventions delivered [23].These included role-plays, supervised patient interviews and form comple-tion demonstrating completion of key elements of theintervention. In the study by Gilbert et al., the interven-tion used a computerised ‘Video Doctor’, which stand-ardised messages, which the authors report may havehelped increase fidelity to the principles of MotivationalInterviewing [24].

Discussion

The objective of this review was to identify the inter-ventions for alcohol or illicit drug misuse problemsevaluated for hospital outpatient populations and deter-mine, from the available evidence, which of theseinterventions can be effectively delivered for thesepopulations.

Interventions for alcohol misuse

The results from this review suggest that interventionsbased on motivational techniques may be effectiveamong patients with alcohol problems identified inoral–maxillofacial clinics. However, the optimumnature and duration of the intervention in this popula-tion group is unclear and would be worthy of further

Tab

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Inte

rven

tions

inou

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anov

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stud

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[18]

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3)[1

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[21]

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research. Nor is it clear if women would respondequally to the intervention as the samples comprisedmainly of men.

The three other trials [20–22], conducted in diversesettings, did not generally find positive effects of briefinterventions to decrease alcohol consumption andrelated outcomes. Chang et al. suggest their findingswere due to reactivity to the assessment that lasted anhour; regression to the mean; and presence of medicalconditions that may motivate changes in drinking inboth groups [20]. Similarly, the study by Emmen et al.also included a lifestyle assessment that was received byboth groups [21].

Nonetheless, these findings cannot be taken asdefinitive as most of the trials had weaknesses, includ-ing issues with randomisation and inadequatefollow-up periods. Importantly, most of the studiesfailed to provide adequate detail about the interventioncontent, duration, intensity and delivery. Such lack ofclarity raises issues when trying to compare interven-tions. There is a need for further good quality studieswith adequate follow-up and full reporting of interven-tion content. The authors of the included studies alsoidentified issues that need to be taken into account inthe planning of future research. These are: reactivity tothe assessment, the possible exclusion of those withsevere alcohol dependence and ensuring that controlsdo not receive part of the intervention.The evidence is,therefore, currently insufficient to state whether or notinterventions to reduce alcohol consumption andrelated outcomes are helpful in general outpatientsettings.

The transferability of findings from other health-caresettings, including inpatient and emergency settingswith their different systems, into an outpatient setting isnot clear, but it may be interesting to compare ourfindings with that of primary care where both settingsprovide a similar type of time-limited consultation situ-ation. A review conducted by Kaner et al. [28] consid-ered studies evaluating the effectiveness of briefinterventions delivered in primary care settings, pub-lished up to early 2007.Their meta-analysis of 22 RCTsfound that intervention participants had lower alcoholconsumption than control participants after follow-upof 1 year. However, the benefits for women wereunclear, and the authors recommended furtherresearch to establish the most effective components ofbrief interventions.

We are aware of two ongoing trials evaluating inter-ventions for alcohol misuse in outpatient settings thathave not yet reported results [29,30]. One of these is anintensive three-arm family-based intervention study foryoung people [30], comparing a MultidimensionalFamily Therapy [an outpatient family-based treatmentfor troubled youths of 3 months duration with an

average of two sessions (60–90 min) per week withadditional extra-familial work and phone contacts asneeded], Family Motivational Interviewing (two homesessions within 72 h of the incident, and link with grouptreatment lasting 3 months) and standard care (two90-min group sessions per week for 3 months). Theother is in HIV-positive women [29], looking tocompare a brief counselling intervention including twosessions that review drinking patterns and behaviourchange strategies, plus two telephone calls to reinforcesession content versus standard care. There is a clearneed for trials of interventions for alcohol misuse inoutpatient settings.

Interventions for drug misuse

The evidence for interventions to reduce drug misusein hospital outpatient settings is limited to one trial[23], and currently, the evidence is insufficient to allowany conclusions to be derived about effectiveness. Thesuggestion that motivational interviewing with abooster call might be more effective than written advicefor adults in outpatient settings would be strengthenedby a trial with longer follow-up (12 months or more)analysed on an intention-to-treat basis. Furtherresearch is necessary. There appears to be no ongoingresearch investigating interventions for drug misuse inoutpatient settings.

Interventions for both alcohol and drug misuse

The evidence on interventions to address both alcoholand drug problems in outpatient settings is limited toone trial [24], which showed an impact on ongoingdrug use but not on cessation of risky drinking. Morestudies evaluating this intervention are needed, andtherefore it is not yet possible to draw conclusions onthe effectiveness of interventions for both alcohol anddrug use in this setting with adults or young people.Further research is needed to consider the effectivenessof combined interventions for alcohol and drug misuseacross in outpatient settings, particularly as we did notidentify any ongoing research investigating interven-tions for both alcohol and drug misuse in this setting.

Interventions for drugs alone and drugs in additionto alcohol appear to be very under-researched areas,and there is a need for much more practical ground-work in terms of identifying likely areas whereapproaching these groups may be feasible and researchachievable.

Poor reporting of methodology, including randomi-sation and allocation concealment procedures, is acommon problem across the clinical trial literature[31]. Follow-up was too short (<12 months) in threestudies reviewed here [21,23,24], making it difficult to



determine long-term effects. The lack of detail andclarity regarding the actual content of interventions,duration, delivery mode and personnel delivering thetreatment was challenging. Additionally, it was oftenunclear on what theoretical framework the interven-tions were based or the behavioural techniques actuallyused. Related to this is the reporting of interventionfidelity, crucial for complex interventions. Adherence toan intervention delivery protocol can influence effec-tiveness [32–36]. Ensuring fidelity can reduce the riskof erroneous conclusions such as concluding that theintervention is ineffective, when in fact it was not imple-mented correctly [37,38]. Across this review, reportingwas mixed.

In addition, where studies appeared to have used thesame type of intervention (e.g. motivational interview-ing), the interpretation of that intervention can be verydifferent. Even where core principles are used, differ-ences may occur in the delivery of the intervention(timing, duration, intensity and interventionist),although often it was difficult to tell differences andsimilarities due to lack of reported detail.

The range of outcomes investigated in the includedstudies demonstrates the variety of measures for alcoholconsumption currently utilised, and it would be benefi-cial to reach consensus on the most useful measures.Additionally, various authors have highlighted the issueof assessment reactivity [39,40], a feature that shouldnot be ignored and given due consideration in studydesign and analysis. In outpatient settings, where mostare not actively seeking treatment for their alcohol con-sumption, and additional health problems may be con-tributing to their reason for attendance, identificationand recruitment of research participants may be a likelyproblem and one where screening and assessment canplay an important part.

Future studies should bear in mind the quality issueshighlighted in the review of the current evidence. Inaddition, the theoretical framework on which the inter-ventions are based, as well as the behaviour changemechanisms underpinning them, should be reported.Attention is also required regarding who should deliverthe intervention, mode of delivery, level of patientcontact and intervention intensity. It would be of inter-est in future to investigate the effect on outcomes otherthan alcohol or drug consumption (e.g. injury rates andcriminal offences). Studies exploring how particularsubgroups respond differently to the intervention (e.g.women and dependent drinkers) would be worth atten-tion, as would the impact of interventions on socialhealth inequalities. Practitioners may want to give someconsideration to particular initiatives aimed at areaswhere there are high levels of specific alcohol problems(e.g. injuries). Researching implementation schemesthat deliver interventions in such areas and that are

geared towards local needs may prove highly interest-ing. In addition, with none of the included studiesincorporating a cost-effectiveness analysis, morethought needs to be given to this aspect of alcohol/drugmisuse prevention interventions in outpatient settings.

Strengths and weakness of this review

This review was conducted according to national guid-ance [14]. Searches included electronic and printsources and of grey literature. As interventions foralcohol and drug misuse are an active area of primaryresearch, authors of ongoing and unpublished studieswere contacted, and details of these are included. Studyselection, data extraction and quality assessment wereconducted by more than one reviewer with disagree-ments resolved by consensus or referral to the projectteam. Therefore, our results should have a low risk ofbias. Despite our best efforts, it is possible that studieshave been missed particularly those reported in lan-guages other than English.

Conclusions

Further research is needed to investigate interventionsfor alcohol and drug misuse in outpatient settings. Thetype of intervention(s) needed to reduce consumptionof alcohol and/or drugs for different groups of patientsin diverse hospital settings is still to be determined.

Acknowledgements

We acknowledge funding from National Institutefor Health Research Collaboration for Leadership inApplied Health Research and Care (NIHR CLAHRC)for Leeds, York and Bradford, which is a partnershipbetween the NHS, social care and academia.The viewsand opinions expressed in this paper are those of theauthors and not necessarily those of the NationalHealth Service, the National Institute for HealthResearch or the Department of Health.

Other contributions

We acknowledge, with thanks, the trialists who gaveadditional information on ongoing or completed trials.We are grateful to Alexis Llewellyn for help with dataextraction.

References

[1] World Health Organization. Global status report on alcoholand health. Geneva: World Health Organization, 2011.

[2] World Health Organization. The world health report.Geneva: World Health Organization, 2002.



[3] National Institute for Health and Clinical Excellence.Alcohol-use disorders: diagnosis, assessment and manage-ment of harmful drinking and alcohol dependence.London: National Institute for Health and Clinical Excel-lence, 2011.

[4] The NHS Information Centre. Statistics on alcohol:England. London: The Health and Social Care InformationCentre, 2009. Available at: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/alcohol/statistics-on-alcohol-england-2009-[ns] (accessed May 2011).

[5] The NHS Information Centre. Statistics on drug misuse:England. London: The Health and Social Care InformationCentre, 2009. Available at: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/drug-misuse/statistics-on-drug-misuse-england-2009 (accessed May2011).

[6] Mitka M. ‘Teachable moments’ provide a means forphysicians to lower alcohol abuse. JAMA 1998;279:1767–8.

[7] Home Office. Drug-related crime. Available at: http://webarchive.nationalarchives.gov.uk/+/homeoffice.gov.uk/crime-victims/reducing-crime/drug-related-crime.html(accessed September 2010).

[8] National Audit Office. Reducing alcohol harm: healthservices in England for alcohol misuse. 2008. Available at:http://www.nao.org.uk/publications/0708/reducing_alcohol_harm.aspx (accessed July 2012).

[9] Apodaca T, Miller W. A meta-analysis of the effectivenessof bibliotherapy for alcohol problems. J Clin Psychol2003;59:289–304.

[10] McQueen J, Howe TE, Allan L, Mains D, Hardy V. Briefinterventions for heavy alcohol users admitted to generalhospital wards. Cochrane Database Syst Rev 2011;(8):CD005191. DOI: 10.1002/14651858.CD005191.pub3.

[11] Emmen MJ, Schippers GM, Bleinjenberg G, WollersheimH. Effectiveness of opportunistic brief interventions forproblem drinking in a general hospital setting: systematicreview. BMJ 2004;328:318–20.

[12] Nilsen P, Baird J, Mello MJ, et al. A systematic review ofemergency care brief alcohol interventions for injurypatients. J Subst Abuse Treat 2008;35:184–201.

[13] Havard A, Shakeshaft A, Sanson-Fisher R. Systematicreview and meta-analyses of strategies targeting alcoholproblems in emergency departments: interventions reducealcohol-related injuries. Addiction 2008;103:368–76.

[14] Centre for Reviews and Dissemination. Systematic reviews:CRD’s guidance for undertaking reviews in health care, 3rdedition. York: University of York, 2009.

[15] Stade BC, Bailey C, Dzendoletas D, Sgro M, Dowswell T,Bennett D. Psychological and/or educational interventionsfor reducing alcohol consumption in pregnant womenand women planning pregnancy. Cochrane DatabaseSyst Rev 2009;(2):CD004228. DOI: 10.1002/14651858.CD004228.pub2.

[16] Burns E, Gray R, Smith LA. Brief screening questionnairesto identify problem drinking during pregnancy: a systematicreview. Addiction 2010;105:601–14.

[17] Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMAGroup. Preferred reporting items for systematic reviewsand meta-analyses: the PRISMA statement. Plos Med2009;6:e1000097.

[18] Goodall CA, Ayoub AF, Crawford A, et al. Nurse-deliveredbrief interventions for hazardous drinkers with alcohol-related facial trauma: a prospective randomised controlledtrial. Br J Oral Maxillofac Surg 2008;46:96–101.

[19] Smith AJ, Hodgson RJ, Bridgeman K, Shepherd JP. A ran-domized controlled trial of a brief intervention afteralcohol-related facial injury. Addiction 2003;98:43–52.

[20] Chang G, Fisher NDL, Hornstein MD, et al. Brief inter-vention for women with risky drinking and medical diag-noses: a randomized controlled trial. J Subst Abuse Treat2011;41:105–14.

[21] Emmen MJ, Schippers GM, Wollersheim H, Bleijenberg G.Adding psychologist’s intervention to physicians’ advice toproblem drinkers in the outpatient clinic. Alcohol Alcohol2005;40:219–26.

[22] Persson J, Magnusson PH. Early intervention in patientswith excessive consumption of alcohol: a controlled study.Alcohol 1989;6:403–8.

[23] Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Lev-enson S, Hingson R. Brief motivational intervention at aclinic visit reduces cocaine and heroin use. Drug AlcoholDepend 2005;77:49–59.

[24] Gilbert P, Ciccarone D, Gansky SA, et al. Interactive ‘VideoDoctor’ counseling reduces drug and sexual risk behaviorsamong HIV-positive patients in diverse outpatient settings.PLoS ONE 2008;3:e1988.

[25] Abraham C, Michie S. A taxonomy of behavior changetechniques used in interventions. Health Psychol 2008;27:379–87.

[26] Stibler H. Carbohydrate—deficient transferrin in serum: anew marker of potentially harmful alcohol consumptionreviewed. Clin Chem 1991;37:2029–37.

[27] Tynjälä T, Kangastupa P, Laatikainen T, Aalto M, NiemeläO. Effect of age and gender on the relationship betweenalcohol consumption and serum GGT: time to recalibrategoals for normal ranges. Alcohol Alcohol 2012;47:558–62.

[28] Kaner EF, Dickinson HO, Beyer FR, et al. Effectiveness ofbrief alcohol interventions in primary care populations.Cochrane Database Syst Rev 2007;(2):CD004148. DOI:10.1002/14651858.CD004148.pub3.

[29] Brief therapy intervention for heavy/hazardous drinking inHIV-positive women. Available at: http://ClinicalTrials.gov/show/NCT00127231 (accessed January 2012).

[30] Family intervention for teen drinking in the ER. Availableat: http://ClinicalTrials.gov/show/NCT01229748 (accessedJanuary 2012).

[31] Hewitt C, Hahn S, Torgerson DJ, Watson JD, Bland JM.Adequacy and reporting of allocation concealment: reviewof recent trials published in four general medical journals.BMJ 2005;330:1057–8.

[32] Shadish WR. Revisiting field experimentation: field notesfor the future. Psychol Methods 2002;7:3–18.

[33] Benner GJ, Nelson JR, Stage SA, Ralston NC. The influ-ence of fidelity of implementation on the reading outcomesof middle school students experiencing reading difficulties.Remedial Spec Educ 2011;32:79.

[34] Dane AU, Schneider BH. Program integrity in primary andearly secondary prevention: are implementation effects outof control? Clin Psychol Rev 1998;18:23–45.

[35] Glasziou P, Chalmers I, Altman D, et al. Taking healthcareinterventions from trials to practice. BMJ 2010;341:c3852.

[36] Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci D, OryM. Enhancing treatment fidelity in health behavior changestudies: best practices and recommendations from the NIHBehavior Change Consortium. Health Psychol 2004;23:443–51.

[37] Horner S, Rew L, Torres R. Enhancing intervention fidelity:a means of strengthening study impact. J Spec Pediatr Nurs2005;11:80–9.



[38] Spillane V, Byrne MC, Byrne M, Leathem C, O’Mallery M,Cupples M. Monitoring treatment fidelity in a randomisedcontrolled trial of a complex intervention. J Adv Nurs2007;60:343–52.

[39] Walters ST, Vader AM, Harris R, Jouriles EN. Reactivity toalcohol assessment measures: an experimental test. Addic-tion 2009;104:1305–10.

[40] McCambridge J, Kypri K. Can simply answering researchquestions change behaviour? Systematic review and metaanalyses of brief alcohol interventions trials. PLoS ONE2011;6:e23748. doi:10.1371/journal.pone.0023748.

Supporting information

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Appendix S1 Full search strategies on Alcohol Abuseand Alcoholism.



Interventions for alcohol and drug problems in outpatient settings: A systematic review

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