FACT SHEET SEVENTEEN

BRIEF INTERVENTIONS

Where do they come from?

With some 1.5 million adults drinking at levels which are dangerous to health, the sheer prevalence of drinking problems surpasses the capacity of specialist services to cope.  This statistic alone has encouraged a search for simpler, briefer and less intensive forms of treatment over the last twenty years.

Early history

Several research studies in the late 1970s compared different durations of inpatient stay; intensive as opposed to simpler inpatient programmes; and inpatient contrasted with outpatient programmes.  A few also studied ways of improving the very low intake of referrals to specialised treatment and found that a brief session with a trained and empathetic counsellor encouraged people who were reluctant to undergo treatment.

A key study was carried out by Edwards and Orford in 1977, comparing male alcoholics who received ‘treatment’ – a full panoply of psychiatric help, group meetings and inpatient care – with those who merely received ‘advice’ – assessment of their drinking, advice and the message that dealing with their problems was their own responsibility.  After one year, little difference was found between the two groups.(1)    Subsequently several researchers investigated the effectiveness of similar advice sessions – brief interventions – as opposed to more intensive treatment.  What had originally begun as the baseline in experimental conditions was perceived to be effective in its own right, and further studies compared this style of intervention with the effects of receiving no intervention at all.  Some studies were based in hospital wards, some in general practice.  Many, but not all, found that brief interventions did have some impact on reducing drinking levels and alcohol related problems in some people.

At the same time, similar sessions, consisting of assessment, advice and self help materials were shown to be successful in reducing smoking, and GPs adopted these.  But they were less enthusiastic about tackling alcohol problems, having been deterred by their lack of success with severely dependent drinkers.  Except for a few committed GPs, brief interventions in the 80s were mainly confined to a research setting.

Added Impetus

By the end of the decade, alcohol problems had been put clearly on the healthcare agenda.  The promotion of healthy lifestyles had become part of the new working arrangements for primary health care: the government strategy.  Health of the Nation, specified targets which both explicitly and implicitly included a reduction in drinking levels.

New arrangements for health promotion were introduced in 1993 and about 90% of GP practices chose to offer the highest level programmes prioritising the reduction of stroke and coronary heart diseases.  Advice on reducing alcohol consumption is an integral part of this work.

Research findings

The findings of the research carried out so far have been collated and summarised in two recent, well publicised reviews, one by T H Bien and colleagues, the other by the Effective Health Care Team. (2) (3)

Bien and his colleagues examined 44 controlled studies from 14 countries.  These studies include research in general healthcare settings, with self-referred drinkers and in specialist contexts.  They include studies that compare intensive treatment to simple intervention (as in the Edwards and Orford example above) and those that compare giving assessment and advice to no form of treatment, such as the extensive experiment carried out by the Wold Health Organisation in ten countries.

The examined the methodological weaknesses of the research – in some the sample sizes are too small; in some cases the researchers were unable to keep the groups they were comparing separate; in some cases the process of follow-up is akin to further interventions.  Not all the studies are directly comparable; some screen out those with existing problems and they use different measures of successful outcomes.

Recognising the variety approaches studied, they pick out the following defining elements:

F            feedback            assessment and evaluation of the problem

R            responsibility            emphasising that drinking is by choice

A         advice             explicit advice on changing drinking behaviour

M         menu               offering alternative goals and strategies

E            empathy        the role of counsellor is important

S         self – efficacy            instilling optimism that the chosen goals can be achieved

They conclude brief interventions;

The review carried out by the Effective Health Care was similar in scope and overall findings, but its conclusions stress the cost – effectiveness of brief interventions.

Challenges to the Research

Brief interventions must not be seen as a panacea – and a less expensive option than conventional treatment – for those with alcohol problems, warns Nick Heather in an analysis of reviews in their effectiveness. (4)  He criticises two recent reviews on three grounds.

Practice examples

apas in Nottingham has offered surgery based interventions since 1993 and has provided informal training sessions to practice staff throughout the country.  They have also run accredited postgraduate seminars for GPs and have drawn up the alcohol protocol for Nottinghamshire GPs. (5)  The project has subsequently been integrated into the apas main Service Agreement.

Health outcomes project, Norfolk

East Norfolk Health Commission supported a project which worked with seven GP practices for two years, measuring staff recording of patients drinking levels, the effectiveness of health promotion and the results of interventions with patients drinking over recommended levels.  During the project, training was provided for practice nurses and other staff, and a variety of health education materials about alcohol was displayed in the surgeries. Copies of the Health Education pack, Cut down on your drinking  which includes material for both staff and patients, were distributed.

By the end of the project, the co-ordinator of the project found:

·        Improved recording of patients’ alcohol consumption – more patients were screened, and the information gained was more accurate.

·        The confidence of practice staff in dealing with alcohol issues had improved.

·        Patients knew more about sensible drinking, though they hadn’t necessarily changed their attitudes or habits.

·        A reduction in alcohol intake in some patients drinking over the recommended limits. (6)

Bedfordshire GP Project (7)

This project aimed to increase the accessibility of alcohol services for people in rural areas.  Over a four year period it worked intensively with three general practices, offering them:

The project has now entered a new phase, offering practices throughout Bedfordshire three short training sessions covering services and resources; data collection and screening; and brief interventions.  It aims to ensure that all primary healthcare teams in the county have the skills, information and support to deal appropriately with alcohol problems.

Hillingdon FHSA appointed an alcohol advisor as part of an innovative programme gauging the effectiveness of brief general practice interventions in dealing with drinking problems.  The advisor found that such minimal intervention had a 20% success rate in improving patients’ health.  However, the report also revealed a lack of confidence among GPs in their ability to deal with alcohol problems.  It also identified a need for a community detoxification service, to be provided by doctors with appropriate training.  Referrals to the local alcohol counselling service increased four – fold during the two years of the project.

Kent Council on Addiction have several counsellors attached to GP practices throughout the county, who offer information and counselling to any patient worried about their drug or alcohol use or referred by the practice.  They also work with practice staff in raising awareness of alcohol and drug use amongst patients.  Several alcohol agencies run similar schemes.

This fact sheet was written by Fran Walker for Alcohol Concern’s AGM, November 1995 and amended by apas, Nottingham, 1996.