Alcoolismo tratamento e abordagem

Treatment overview:
brief interventions
brief interventions may reduce mortality in heavy drinkers (level 2 [mid-level] evidence)
brief primary care physician intervention can decrease alcohol use, problem drinking and hospitalization in problem drinkers (level 1 [likely reliable] evidence)
brief interventions in primary care settings may reduce alcohol consumption in hazardous drinkers, including patients not specifically seeking alcohol-related treatment (level 2 [mid-level] evidence)
longer-term psychologic interventions with evidence for efficacy include
cognitive behavioral therapy (level 2 [mid-level] evidence)
network support (to help patient change social network) (level 2 [mid-level] evidence)
behavioral couple therapy (for females with alcohol use disorder) (level 2 [mid-level] evidence)
integrated medical and substance abuse treatment appears to improve abstinence rates at 6 months in patients with substance-abuse related medical conditions (level 2 [mid-level] evidence)
pharmacologic therapy may have adjunctive role
disulfiram (Antabuse) produces unpleasant symptoms with small amounts of alcohol
500 mg orally once daily, may reduce dose if sedation
may reduce days of drinking but not improve total abstinence (level 2 [mid-level] evidence)
naltrexone (Depade, ReVia, generic) is opiate antagonist
50 mg orally once daily; alternative is naltrexone 380 mg (Vivitrol) intramuscularly every 4 weeks
naltrexone appears to reduce heavy drinking and relapse rate (level 2 [mid-level] evidence)
acamprosate (Campral) has different mechanism of action
666 mg orally 3 times daily with meals
acamprosate may reduce risk of drinking after completion of detoxification in alcohol dependent patients (level 2 [mid-level] evidence)
acamprosate and naltrexone may similarly reduce risk for drinking after detoxification in alcohol dependent patients (level 2 [mid-level] evidence), evidence for combination therapy limited and conflicting
sertraline plus naltrexone may increase abstinence rate and decrease depression symptoms compared to either sertraline or naltrexone alone for patients with depression and alcohol dependence (level 2 [mid-level] evidence)
anticonvulsants may reduce alcohol consumption in adults with alcohol dependence (level 2 [mid-level] evidence)
topiramate (Topamax) (off-label use of antiepileptic drug)
25 mg orally once daily titrated to 150 mg orally twice daily
topiramate may reduce heavy drinking and may improve quality of life but often not tolerated (level 2 [mid-level] evidence)
gabapentin associated with increased abstinence and reduced heavy drinking in adults with alcohol dependence (level 2 [mid-level] evidence)
baclofen (Lioresal) may be effective for maintaining alcohol abstinence in patients with alcoholic cirrhosis, and may reduce alcohol craving and intake (level 2 [mid-level] evidence)
ondansetron (Zofran) may be effective in reducing drinking in early-onset alcoholics (level 2 [mid-level] evidence)
insufficient evidence from randomized trials regarding effectiveness of 12-step programs, but observational evidence suggests Alcoholics Anonymous (AA) attendance may reduce alcohol consumption and depressive symptoms (level 2 [mid-level] evidence)
combination of smoking cessation intervention plus alcohol intervention may decrease alcohol consumption and increase long-term abstinence rates (level 2 [mid-level] evidence)
Diet:
advise nutritional intake to achieve Dietary Reference Intakes (N Engl J Med 2009 Jun 25;360(26):2758)
Counseling:
behavioral counseling may reduce alcohol consumption in patients with alcohol use disorder (level 2 [mid-level] evidence)
based on systematic review limited by clinical heterogeneity
systematic review of 23 randomized trials (with duration ≥ 6 months) evaluating behavioral counseling for adolescents and adults with alcohol use disorder
behavioral counseling interventions varied across studies and included
brief advice, feedback, or motivational interviews
cognitive behavioral strategies, such as self-completed action plans, written health education or self-help materials
drinking diaries
problem-solving exercises
control interventions included usual care, educational materials, and advice from nurse
compared to control interventions at 12 months, behavioral counseling associated with
reduced alcohol consumption
in adults (mean difference 3.6 drinks/week, 95% CI 2.4-4.8 drinks/week) in analysis of 10 trials with 4,332 patients
in young adults/college students (mean difference 1.7 drinks/week, 95% CI 0.7-2.6 drinks/week) in analysis of 3 trials with 1,421 patients
reduced heavy drinking episodes (risk difference 12%, 95% CI 7%-16%) in analysis of 7 trials with 2,727 adult patients
increased number of patients achieving recommended drinking limit (risk difference 11%, 95% CI 8%-13%) in analysis of 9 trials with 5,973 adult patients
insufficient evidence to draw conclusions about effect of behavioral counseling on accidents, injuries, or alcohol-related liver problems in adults
Reference - Ann Intern Med 2012 Nov 6;157(9):645 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost
motivational interviewing and cognitive behavioral therapy may reduce alcohol misuse in patients with comorbid depression or anxiety disorders (level 2 [mid-level] evidence)
based on systematic review limited by clinical heterogeneity
systematic review of 8 randomized trials comparing different psychological interventions for alcohol misuse in patients with comorbid depression or anxiety disorders
meta-analysis precluded by heterogeneity in patient characteristics and treatment regimens
motivational interviewing and cognitive behavioral interventions associated with significant reductions in alcohol consumption and depressive and/or anxiety symptoms
longer interventions generally more effective than brief interventions
Reference - J Affect Disord 2012 Aug;139(3):217
psychosocial interventions for decreasing alcohol consumption in adults with problematic drug and alcohol use have limited evidence to evaluate efficacy and adverse effects
based on Cochrane review
systematic review of 4 randomized trials evaluating psychosocial interventions for reducing alcohol consumption in 594 adults with problematic drug and alcohol use
meta-analysis precluded by heterogeneity in comparisons and outcome measures
brief motivational intervention decreased alcohol consumption vs. assessment only in 1 trial with 187 adults
no significant difference in alcohol consumption comparing
brief intervention on alcohol use vs. treatment as usual in 1 trial with 110 adults
cognitive-behavioral coping skills training vs. 12-step facilitation in 1 trial with 41 adults
hepatitis health promotion vs. individual or group motivational interviewing in 2 trials with 324 adults
Reference - Cochrane Database Syst Rev 2014 Dec 3;(12):CD009269
early interventions may reduce frequency and quantity of alcohol use in adolescents (level 2 [mid-level] evidence)
based on systematic review without assessment of allocation concealment
systematic review of 9 randomized and quasi-randomized trials comparing early interventions to usual care for substance use in 1,895 adolescents aged 13-19 years using alcohol or other drugs but not meeting criteria for abuse or dependence
interventions included motivational interviewing, life skills training, antiviolence models, and value clarification procedures
5 trials evaluated frequency or quantity of alcohol use
early interventions associated with reduced
frequency of alcohol use in analysis of 5 trials (p = 0.008), results limited by significant heterogeneity
quantity of alcohol use in analysis of 4 trials (p = 0.0004)
episodes of binge drinking in analysis of 4 trials (p = 0.001)
Reference - Subst Abuse Treat Prev Policy 2012 Jun 14;7(1):25 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost PDF
Brief interventions:
United States Preventive Services Task Force (USPSTF) recommends screening adults ≥ 18 years old for alcohol misuse and providing persons engaging in risky or hazardous drinking with brief behavioral counseling to reduce alcohol misuse (USPSTF Grade B)(3)
brief interventions may include
motivational interviews of varying length and number
cognitive behavioral therapy
self-completed action plans
written health-education or self-help materials
requests to keep drinking diaries
written personalized feedback
follow-up telephone counseling
exercises to complete at home
brief interventions may reduce mortality in heavy drinkers (level 2 [mid-level] evidence)
based on systematic review with clinical heterogeneity
systematic review of 4 randomized trials with 1,540 heavy drinkers
follow-up time frames varied from 1-10 years
3 of 4 trials excluded heavy drinkers who were alcohol dependent
one study was limited to only patients ≥ 65 years old
brief interventions varied in duration, frequency, and manner of delivery
pooled relative risk of death for brief intervention 0.47 (95% CI 0.25-0.89)
Reference - Addiction 2003 Jul;99(7):839 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost
personalized feedback interventions delivered in person or by computer may have similar efficacy for decreasing short-term alcohol use and alcohol-related problems in adolescents and young adults (level 2 [mid-level] evidence)
based on systematic review without assessment of trial quality
systematic review of 13 randomized trials comparing in-person vs. computer-delivered personalized feedback interventions for alcohol misuse in 2,441 adolescents and young adults
mean participant age ranged from 16.8 to 20.6 years across trials, 9 trials conducted in college students
follow-up ranged from 1 to 15 months, short-term follow-up defined as ≤ 4 months
comparing in-person to computer-delivered personalized feedback interventions
no significant differences in any alcohol use variables or alcohol related problems at short-term follow-up
in-person personalized feedback interventions associated with significantly reduced drinks per week and alcohol quantity at > 4 months in analyses of 5 trials with 635 participants
no other differences between groups at > 4 months
Reference - J Consult Clin Psychol 2015 Apr;83(2):430 full-text
Brief interventions in primary care:
brief primary care physician intervention can decrease alcohol use, problem drinking and hospitalization in problem drinkers (level 1 [likely reliable] evidence)
based on randomized trial
774 problem drinkers aged 18-65 years (482 men and 292 women) randomized to receive either workbook-based intervention during two 15-minute physician visits 1 month apart (and contract to reduce alcohol intake) vs. booklet on general health
problem drinkers defined as men who consumed > 14 drinks (168 g)/week and women who had > 11 drinks (132 g)/week, or > 5 drinks at least 4 times in past month
intervention consisted of 2 physician visits and 2 nurse follow-up phone calls covering review of normative drinking, patient-specific alcohol effects, worksheet on drinking cues, drinking diary cards, and drinking agreement in prescription format
adults in 17 private community-based primary care practices in Wisconsin completed health screening survey
a drink in this study contains 12 g of alcohol
comparing workbook-based intervention vs. control at 12 months
women decreased alcohol consumption by 47% vs. 16% (p < 0.001, NNT 4)
men decreased alcohol consumption by 37% vs. 23% (p < 0.001, NNT
total days of hospitalization in men 178 vs. 314 (p < 0.01)
no differences in days of hospitalization in women
intervention significantly reduced 7-day alcohol use, number of binge drinking episodes, frequency of excessive drinking; trend toward fewer emergency department visits, nonsignificant reduction in mortality
Reference - Project TrEAT - Trial for Early Alcohol Treatment (JAMA 1997 Apr 2;277(13):1039)
at 4-year follow-up, no significant differences between treatment and control groups in overall drinking rates, in rates of heavy drinking in men, or in binge drinking rates in women
significant differences seen between treatment and control groups in female heavy drinkers (consuming > 13 drinks in previous 7 days) and male binge drinkers (consuming > 5 drinks on one occasion in previous 30 days)
Reference - Alcohol Clin Exp Res 2002 Jan;26(1):36
brief interventions may reduce problem drinking in women of childbearing age (level 2 [mid-level] evidence)
based on subgroup analysis of randomized trial
205 women randomized to intervention (two 15-minute physician visits with advice, education and contracting using scripted workbook) vs. control
174 (85%) completed 48 months of follow-up
intervention significantly reduced 7-day alcohol use (p = 0.0039) and binge drinking episodes (p = 0.0021) throughout 48 months
Reference - Project TrEAT (Alcohol Clin Exp Res 2000 Oct;24(10):1517)
net benefit seen when costs analyzed from societal perspective (ACP J Club 2002 Sep-Oct;137(2):58 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost)
subgroup analysis of 226 young adults ≤ 30 shows significant difference in heavy drinking rates between groups sustained at 36 months (Ann Fam Med 2004 Sep-Oct;2(5):474 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text)
multifaceted intervention may reduce at-risk drinking at 3 months but not at 12 months in older adults (level 2 [mid-level] evidence)
based on randomized trial with high loss to follow-up
631 adults ≥ 55 years old considered at-risk drinkers by Comorbidity Alcohol Risk Evaluation Tool (CARET) were randomized to multifaceted intervention in primary care vs. control
intervention included personalized report on alcohol associated risk behaviors, educational booklet on alcohol and aging, drinking diary, discussion with written advice from primary care provider, and motivational interviewing telephone counseling from health educator to reduce alcohol consumption at 2, 4, and 8 weeks
control included booklet outlining recommended behaviors for alcohol use, nutrition, exercise, medication use, smoking, and encouragement to discuss with primary care physician
21% lost to follow-up at 12 months
comparing intervention vs. control at 3 months
proportion of patients considered at-risk drinker 49.6% vs. 61.2% (adjusted odds ratio [OR] 0.41, 95% CI 0.22-0.75)
≥ 1 heavy drinking days in previous 7 days in 10.3% vs. 16.9% (adjusted OR 0.46, 95% CI 0.22-0.99)
no significant differences for either outcome at 12 months
Reference - Addiction 2011 Jan;106(1):111 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text
physician advice can decrease excessive alcohol use by older adults (level 1 [likely reliable] evidence)
based on randomized trial
158 patients > 65 years old randomized to intervention (general health booklet and two 10-15 minute physician-delivered counseling sessions 1 month apart including advice, education and contracting using scripted workbook) vs. control (general health booklet) and followed every 3 months for 1 year
nurse contacted patient by phone 2 weeks after each visit
inclusion criteria
men consuming > 11 drinks/week or binge drinking (> 4 drinks per occasion 2 or more times in past 3 months)
women consuming > 8 drinks/week or binge drinking (> 3 drinks per occasion 2 or more times in past 3 months)
2 or more positive responses to CAGE questionnaire
patients excluded if attended alcohol treatment program or had symptoms of alcohol withdrawal in previous year, had physician advice to change alcohol use in previous 3 months, drank > 50 drinks/week or had suicidal ideation
comparing intervention to control at 12 months
mean number of drinks in previous 7 days 9.9 vs. 16.3 (p < 0.001)
binge drinking in previous 30 days in 30.8% vs. 49.3% (p < 0.005, NNT 6)
excessive alcohol use in prior 7 days in 15.4% vs. 34.3% (p < 0.005, NNT 6)
no significant changes in health status
Reference - Project GOAL (J Fam Pract 1999 May;48(5):378), commentary can be found in Evidence-Based Medicine 1999 Nov-Dec;4(6):172
brief physician intervention may reduce binge drinking (level 2 [mid-level] evidence)
based on randomized trial without attention control
752 binge drinkers randomized to brief physician counseling intervention vs. usual care and followed for 12 months
physician intervention was 2 face-to-face counseling sessions (10 to 15 minutes each) during routine patient care plus nurse contact at 2 weeks and 8 weeks to reinforce
comparing physician intervention vs. control at 12 months
binge drinking episodes during previous 30 days in 52.3% vs. 67.2% (p < 0.001, NNT 7)
mean number of binge drinking episodes during previous 30 days 1.14 vs. 1.56 (p < 0.001)
mean number of drinks in previous 7 days 19.2 vs. 22.24 (p < 0.001)
Reference - Am J Med 2010 Jan;123(1):72
brief interventions in primary care settings may reduce alcohol consumption in hazardous drinkers, including patients not specifically seeking alcohol-related treatment (level 2 [mid-level] evidence)
based on 3 systematic reviews with methodologic limitations
Cochrane review with substantial heterogeneity
systematic review of 29 randomized trials comparing brief interventions (not exceeding 4 sessions) for reducing alcohol consumption vs. control treatment delivered in general practice or emergency departments with participants not seeking alcohol treatment
control treatments included assessment only, standard treatment, nonintervention or extended psychological intervention
brief intervention reduced consumption compared to control after ≥ 1-year follow-up (mean difference -38 grams/week, 95% CI -54 to -23 grams/week) in meta-analysis of 22 trials with 7,619 patients (mean age 43 years), results limited by significant heterogeneity
in subgroup analysis of 8 trials with 2,307 participants at 1-year follow-up
benefit found in men (mean difference -57 grams/week, 95% CI -89 to -25 grams/week)
benefit not found in women (mean difference -10 grams/week, 95% CI -48 to 29 grams/week)
nonsignificant trends for greater efficacy with more intervention
increased reduction in consumption of 1 gram/week (95% CI -0.1 to 2.2 grams/week, p = 0.09) for each extra minute of treatment exposure
extended intervention associated with greater reduction in consumption compared to brief intervention (mean difference -28 grams/week, 95% CI -62 to 6 grams/week)
Reference - Cochrane Database Syst Rev 2008 Oct 8;(4):CD004148, Cochrane for Clinicians summary can be found in Am Fam Physician 2009 Mar 1;79(5):370 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost, commentary on earlier version can be found in Evid Based Med 2007 Dec;12(6):179 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost
systematic review of 56 randomized trials without evidence of quality assessment
brief interventions defined as interventions with ≤ 4 sessions
34 trials involved patients not seeking treatment
27 (79%) trials excluded any patients who
drank at high levels or for long period of time
had alcohol dependence
had previous treatment for alcohol problems
brief interventions (compared to no intervention) significantly reduced drinking at 3-12 months, modest benefit after 12 months did not reach statistical significance and results at > 3-6 months follow-up significant only if trials with heavy drinkers excluded
20 trials involved patients seeking treatment and compared brief interventions to patients receiving extended treatment
brief intervention no less effective than extended treatment in 20 trials of patients seeking treatment, but trend for reduced drinking at 3-6 months with extended treatment
authors question definition of brief interventions in some studies, indicating brief interventions in treatment seeking individuals may not meet generally accepted ideas of brief intervention
Reference - Addiction 2002 Mar;97(3):279 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost in ACP J Club 2002 Sep-Oct;137(2):58 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost
systematic review of 19 randomized trials of "brief intervention" or "motivational intervention" with 5,639 outpatients actively attending primary care and not seeking alcohol treatment
intention-to-treat analysis used with no change assumed for patients with missing data
15 trials used customary alcohol intake as inclusion criteria, 14 trials excluded alcohol-dependent patients
9 trials had follow-up rates > 80% (mean 72%, range 32% to 92%)
trial quality ranged from 5 to 14 on 18-point scale (mean 9.6)
high-quality trials (score 10 or higher) were more likely to report statistically significant positive effects than low-quality trials
meta-analysis of 12 trials for outcome of change in alcohol consumption found brief alcohol intervention associated with reduction in alcohol use at 6 or 12 months by 38 g/week (95% CI 24-51 g/week), or about 3 drinks per week, Project TrEAT accounted for about 40% of this analysis
healthcare utilization reported in 3 trials, inconsistent results suggesting benefit or no effect
mortality reported in 1 trial with significant reduction at 3 years but not 4 years
Reference - Arch Intern Med 2005 May 9;165(9):986 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text, commentary can be found in Am Fam Physician 2006 Jan 1;73(1):150
similar results can be found in systematic review of 6 meta-analyses and 1 systematic review (Prev Med 2014 Dec 13 early online)
motivational interviewing may only slightly reduce quantity and frequency of alcohol consumption in young adults (level 2 [mid-level] evidence)
based on Cochrane review of trials with methodologic limitations
systematic review of 66 randomized trials evaluating motivational interviewing for prevention of alcohol misuse in 17,901 patients ≤ 25 years old
all trials had ≥ 1 limitation including
unclear or no allocation concealment
lack of blinding
features of motivational interviewing included awareness, common beliefs about drinking alcohol, and problem-solving or decision-making skills (or both)
comparing motivational interviewing to assessment only or alternative intervention (control) at ≥ 4 months, motivational interviewing associated with
decreased alcohol consumption (equivalent to 1.5 fewer drinks per week vs. control) in analysis of 28 trials with 6,676 patients
lower frequency of alcohol consumption (equivalent to 0.17 day reduction in drinking days per week vs. control) in analysis of 16 trials with 4,390 patients, results limited by significant heterogeneity
fewer alcohol problems (equivalent to 0.7 point reduction on 69 point scale) in analysis of 24 trials with 6,742 patients, results limited by significant heterogeneity
nonsignificant decrease in binge drinking in analysis of 16 trials with 4,028 patients
Reference - Cochrane Database Syst Rev 2014 Aug 21;(:CD007025
trials of screening plus brief intervention for patients who screen positive have inconsistent results
screening for high-risk drinking and 5-10 minutes of advice and counseling during primary care visit may reduce high-risk alcohol consumption (level 2 [mid-level] evidence)
based on trial with cluster randomization and large loss to follow-up
3 primary care internal medicine practice sites randomized to intervention site vs. control with additional control site added 22 months into the trial
9,772 patients aged 21-70 years attending these practices screened for high-risk drinking, defined as any of
men consuming > 12 standard drinks per week (standard drink = 12.8 g of alcohol such as 5 ounces of wine, 12 ounces of beer, or 1.5 ounces of 80-proof liquor)
women consuming > 9 standard drinks per week
binge drinking (5 or more drinks for men, 4 or more drinks for women) in previous month
intervention site providers were asked to provide 5-10 minutes of patient-centered alcohol counseling at next regular patient visit for patients who screened positive for high-risk drinking
1,760 patients screened positive of whom 530 came for another regular patient visit and were included in the study, 447 completed 12-month interview
gender-adjusted outcomes from baseline to 12 months
comparing patients at intervention sites vs. control sites
mean number of drinks per week decreased from 18.3 to 12.6 vs. 16.3 to 13.3
binge drinking episodes per month decreased from 4.8 to 2.6 vs. 3.8 to 2.4
Reference - J Gen Intern Med 2005 Jan;20(1):7 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text, summary can be found in Am Fam Physician 2005 Nov 1;72(9):1867
addition of lifestyle counselling and/or brief advice to patient information leaflet may not reduce hazardous alcohol consumption compared to patient information leaflet alone in adults with alcohol use disorder (level 2 [mid-level] evidence)
based on cluster-randomized trial with low compliance
756 adults (mean age 45 years) who screened positive for alcohol use disorder randomized by primary care practice to 1 of 3 interventions
structured brief advice for 5 minutes plus patient information leaflet
brief lifestyle counselling for 20 minutes plus structured brief advice for 5 minutes plus patient information leaflet
patient information leaflet alone
all patients were not seeking alcohol-related treatment at baseline
provision of patient leaflet and brief advice occurred directly after screening but brief lifestyle counselling was provided in subsequent consultation
57% in brief lifestyle counselling group attended session but 99%-100% in other groups received allocated intervention
no significant difference in negative alcohol use disorders identification test at 6 or 12 months comparing either structured brief advice or brief lifestyle counselling to leaflet alone in intention-to-treat analyses
Reference - SIPS trial (BMJ 2013 Jan 9;346:e8501 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text)
screening and brief intervention in general practice may be ineffective (level 2 [mid-level] evidence)
based on pragmatic controlled trial with low follow-up rate
39 general practitioners randomized to give brief counseling intervention vs. no intervention to patients
906 risky drinkers identified out of 6,897 adults screened
537 (59%) had research follow-up at 12-14 months
of 442 patients exposed to brief counseling session, only 79 (17.9%) attended follow-up consultation offered by general practitioner
average weekly consumption increased by 0.7 drinks in both groups at 1-year follow-up
Reference - Alcohol Alcohol 2007 Nov-Dec;42(6):593 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text
screening for excessive alcohol use and providing brief intervention "created more problems than it solved"
based on qualitative study of 24 generalist physicians who participated in pragmatic study of screening and brief intervention for excessive alcohol use
Reference - BMJ 2002 Oct 19;325(7369):870 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text, commentary can be found in BMJ 2003 Feb 8;326(7384):336 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost, BMJ 2003 Mar 8;326(7388):550 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost
addition of brief intervention to usual care may not reduce alcohol consumption in patients with opiate or cocaine dependence and problematic alcohol use (level 2 [mid-level] evidence)
based on randomized trial with unclear blinding
112 adult outpatients with opiate or cocaine dependence and problematic alcohol use randomized to brief intervention plus treatment as usual vs. treatment as usual alone and followed for 9 months
brief intervention provided by multidisciplinary team of healthcare professionals to promote self-observation in consumption of alcohol
both treatments reduced alcohol consumption from baseline at 3 months (p < 0.05) but not at 9 months
no significant differences between treatments in alcohol consumption at any time point
Reference - Subst Abuse Treat Prev Policy 2011 Aug 17;6:22 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text
Brief interventions in hospital settings:
brief interventions in hospital settings for heavy alcohol users might reduce alcohol consumption and mortality (level 2 [mid-level] evidence)
based on Cochrane review with heterogeneity and trials with methodologic limitations
systematic review of 14 randomized or controlled trials comparing brief interventions to reduce alcohol consumption vs. usual care in 4,041 heavy alcohol users admitted to hospital inpatient units for treatments not related to alcohol use
intervention consisted of 1-3 sessions of counseling focused on reducing alcohol consumption
all but 1 trial had methodologic limitations and this trial did not have full intention-to-treat analysis
brief intervention generally associated with reduction in mean alcohol consumption during subsequent follow-up
at 4 months no significant difference in 1 trial with 616 patients (511 patients analyzed)
at 6 months, statistically significant reduction in analysis of 4 trials with 453 patients analyzed, analysis limited by heterogeneity
at 9 months, statistically significant reduction in 1 trial with 616 patients (511 patients analyzed)
at 1 year, nonsignificant reduction in analysis of 4 trials with 1,073 patients analyzed
limited data reported for measures of heavy drinking
significant reduction in heavy drinking episodes in 1 trial with 616 patients (511 patients analyzed)
no difference in number of binges in 1 trial with 287 patients
brief intervention might be associated with lower mortality during subsequent follow-up
at 3 months no significant difference in 1 trial with 29 patients analyzed
at 4 months no significant difference in 1 trial with 616 patients (520 patients analyzed)
at 6 months, statistically significant reduction in analysis of 4 trials with 1,166 patients analyzed
risk ratio (RR) 0.42 (95% CI 0.19-0.94)
NNT 39-528 with 3% mortality in controls
analysis limited by heterogeneity
at 9 months no significant difference in 1 trial with 616 patients (495 patients analyzed)
at 1 year, statistically significant reduction in analysis of 7 trials with 2,396 patients analyzed
RR 0.6 (95% CI 0.4-0.91)
NNT 37-246 assuming 5% mortality in controls
only 1 of the 7 trials was statistically significant individually
Reference - Cochrane Database Syst Rev 2011 Aug 10;(:CD005191
brief motivational intervention associated with reduced alcohol consumption in injured patients with alcohol dependence (level 2 [mid-level] evidence)
based on randomized trial with high dropout rate
1,336 patients (82% male) in trauma care setting assessed for alcohol dependence randomized to brief motivational interview vs. treatment as usual (informational handouts provided)
follow-up assessment completed by
77% at 6 months
66% at 12 months
brief motivational intervention associated with decreased alcohol consumption (compared to baseline) at
6 months (p = 0.03)
12 months (p = 0.02)
Reference - Drug Alcohol Depend 2010 Sep 1;111(1-2):13
brief intervention no more effective than scripted discharge instructions for patients with hazardous/harmful drinking in emergency department (level 1 [likely reliable] evidence)
based on randomized trial
494 persons ≥ 18 years old reporting hazardous/harmful drinking (mean 13.6 drinks per week) in emergency department randomized to brief (5-10 minute) motivational intervention by physician (Brief Negotiation Interview) vs. scripted discharge instructions
92% completed evaluations at 6 months and 12 months
no significant differences comparing intervention vs. discharge instructions at 12 months
mean drinks per week 9.8 vs. 9.8
binge drinking episodes per month 4 vs. 3.9
Reference - Ann Emerg Med 2008 Jun;51(6):742, editorial can be found in Ann Emerg Med 2008 Jun;51(6):751
brief intervention in emergency department may reduce alcohol consumption and driving after drinking in patients with hazardous/harmful drinking (level 2 [mid-level] evidence)
based on randomized trial with low adherence
889 adults in emergency department with hazardous and harmful drinking randomized to 1 of 4 groups and followed for 12 months
brief motivational intervention by emergency practitioner (Brief Negotiation Interview)
Brief Negotiation Interview with 1-month follow-up telephone booster
standard care with assessments
standard care with no assessments
59% completed interactive voice response assessment at 12 months
Outcomes at 12 Months:
Overall at Baseline Brief Negotiation Interview Brief Negotiation Interview with Telephone Booster Standard Care p for Trend
Mean drinks per week 19.8-20.9 14.3 13 17.6 p = 0.045
Mean binge drinking days during past 28 days 7.2-7.5 5.1 4.7 5.8 p = 0.03
Driving after drinking > 3 drinks > 1 time during past 12 months 38%-43% 29% 31% 42% p = 0.04
no significant differences in reduction in drinks per week or in binge drinking days comparing
Brief Negotiation Interview with vs. without telephone booster
standard care with vs. without assessment
no significant differences between treatments in arrests for driving under influence, motor vehicle crash while intoxicated, contact with legal system, or missing ≥ 1 workday
Reference - Ann Emerg Med 2012 Aug;60(2):181
therapist-delivered brief intervention in emergency department for adolescents with prior alcohol misuse and aggression may reduce alcohol consequences for 6 months and violence consequences for 1 year (level 2 [mid-level] evidence)
based on randomized trial without attention control
726 patients aged 14-18 years presenting to emergency department (ED) for medical illness or injury and who self-reported past-year alcohol misuse and aggression randomized to 1 of 3 treatments delivered in ED
computerized brief intervention for alcohol and violence
therapist-delivered brief intervention for alcohol and violence
brochure for alcohol and violence (control)
all patients completed computerized self-assessment prior to randomization
alcohol consequences included missed school, trouble getting along with friends because of drinking, etc.
patients dropped out of school at baseline (p = 0.02)
14.4% for computerized intervention
7.5% for therapist-delivered intervention
8.5% for control
therapist-delivered intervention associated with significant reductions in (vs. control)
peer aggression at 3 months
experience of peer violence at 3 months
violence consequences at 3 months
alcohol consequences at 6 months
computerized intervention associated with significant reduction in alcohol consequences at 6 months vs. control
Reference - SafERteens trial (JAMA 2010 Aug 4;304(5):527 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text), editorial can be found in JAMA 2010 Aug 4;304(5):575 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost

Prevention:
School-based prevention programs in children and adolescents:
conflicting evidence regarding effectiveness of universal school-based prevention programs for alcohol misuse in school-aged children (level 2 [mid-level] evidence)
based on Cochrane review of mostly low-quality trials
systematic review of 53 randomized trials (51 with cluster randomization) evaluating universal school-based prevention programs for alcohol misuse in school-aged children < 18 years old
heterogeneity of interventions, populations, and outcomes prevented quantitative analysis
6 of 11 trials evaluating alcohol-specific interventions reported some evidence of effectiveness compared to standard curriculum
14 of 39 trials evaluating generic interventions reported greater reduction in alcohol use
inconsistent results found in 3 trials with interventions targeting cannabis, alcohol, and/or tobacco
most commonly observed positive effects across programs were for drunkenness and binge drinking
Reference - Cochrane Database Syst Rev 2011 May 11;(5):CD009113
Drug Abuse Resistance Education (DARE) appears ineffective in preventing use of alcohol, tobacco, or illicit drugs (level 2 [mid-level] evidence)
based on 2 systematic reviews without quality assessment of included trials
meta-analysis of 11 published controlled trials (Am J Public Health 2004 Jun;94(6):1027 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text)
meta-analysis of 20 trials (Int J Environ Res Public Health 2009 Jan;6(1):267 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text)
DynaMed commentary -- most of these trials evaluated the "old DARE model" and DARE prevention program was revised in 2001 so may be more effective, only 2 trials were published after 2001
DARE Plus program in seventh grade may reduce drug use in eighth grade
based on randomized trial
24 schools randomized to DARE vs. DARE Plus vs. delayed program control
DARE Plus activities included youth-led extracurricular activities and community adult action teams
6,237 seventh-grade students evaluated at end of eighth grade
no significant differences in self-reported tobacco, alcohol, and multidrug use and victimization between DARE and control groups
DARE Plus associated with reduced self-reported tobacco, alcohol, and multidrug use and victimization among boys but no significant differences in outcomes among girls
Reference - Arch Pediatr Adolesc Med 2003 Feb;157(2):178 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost full-text, summary can be found in Am Fam Physician 2003 Aug 1;68(3):550
Strengthening Families Program (7 family skills training sessions) and Preparing for the Drug-Free Years (5 family skills training sessions) were each more effective than minimal contact control in reducing initiation and current use of alcohol, tobacco, and marijuana at 4 years
based on randomized trial of 33 public schools
667 students in sixth grade at baseline
Reference - J Consult Clin Psychol 2001 Aug;69(4):627
teacher-delivered personality-targeted intervention associated with reduced alcohol consumption in adolescents (level 2 [mid-level] evidence)
based on cluster-randomized trial without attention control
18 schools randomized to teacher-delivered personality-targeted intervention vs. no intervention with 1,159 high-risk students (mean age 13.7 years) who were followed for 6 months
teacher-delivered personality-targeted intervention was two 90-minute group sessions (mean 6 students) with psychoeducational, motivational enhancement and cognitive-behavioral therapies
teachers received 3 days of training in counseling
all students received drug education in class as part of national curriculum requirements
teacher-delivered personality-targeted intervention associated with
reduced drinking (odds ratio [OR] 0.6, 95% CI 0.4-0.
reduced binge-drinking (OR 0.7, 95% CI 95% CI 0.5-1)
reduced binge-drinking in alcohol users (OR 0.45, 95% CI 0.3-0.
Reference - J Am Acad Child Adolesc Psychiatry 2010 Sep;49(9):954
National Institute for Health and Clinical Excellence (NICE) public health guidance on interventions in schools to prevent and reduce alcohol use among children and young people can be found at NICE 2007 Nov:PH7
Prevention strategies in children and adolescents in non-school settings:
mentoring of adolescents might reduce initiation of drug and alcohol use (level 2 [mid-level] evidence)
based on Cochrane review with limited evidence
systematic review of 4 randomized trials comparing mentoring to no intervention for prevention of alcohol or drug use in 1,194 adolescents
all trials conducted in the United States in nonusers at baseline, with high proportion of minority and disadvantaged adolescents
3 trials evaluated initiation of alcohol use
no significant difference between groups at 6 months in 1 trial with 194 adolescents
mentoring associated with lower initiation rate at 12 or 18 months in analysis of 2 trials with 1,116 adolescents
risk ratio 0.71 (95% CI 0.57-0.9)
NNT 10-42 with 24% initiating alcohol use in no intervention group
3 trials evaluated initiation of drug use
mentoring associated with lower initiation rate at 18 months in 1 trial with 959 adolescents (6% vs. 11%, p = 0.0046, NNT 20)
mentoring associated with trend toward lower initiation rate in 1 trial with 194 adolescents (p = 0.092)
no significant difference between groups in 1 trial with 157 adolescents
no significant difference between groups in substance abuse (including alcohol and drugs) within previous 2 months at 3-year follow-up in 1 trial
Reference - Cochrane Database Syst Rev 2011 Nov 9;(11):CD007381
universal multicomponent prevention programs associated with reduction in alcohol misuse in school-aged children (level 2 [mid-level] evidence)
based on Cochrane review limited by clinical heterogeneity
systematic review of 20 randomized and cluster-randomized trials evaluating universal multicomponent prevention programs (intervention in > 1 setting) for alcohol misuse in school-aged children ≤ 18 years old
meta-analysis precluded by heterogeneity of interventions, populations, and outcomes
control groups were no program in 15 trials, mailed materials in 4 trials, and other active interventions in 1 trial
13 trials reported significant reduction in alcohol use or initiation with universal multicomponent interventions
1 trial found significant benefit of intervention only in subgroup of baseline drinkers
6 trials found no significant differences between groups
Reference - Cochrane Database Syst Rev 2011 Sep 7;(9):CD009307
universal family-based prevention programs associated with reduction in alcohol misuse in school-aged children (level 2 [mid-level] evidence)
based on Cochrane review with clinical heterogeneity
systematic review of 12 randomized trials evaluating universal family-based prevention programs for alcohol misuse in school-aged children ≤ 18 years old
heterogeneity of interventions, populations, and outcomes precluded meta-analysis
interventions included
development of parenting skills including parental support, nurturing behaviors, establishing clear boundaries or rules, and parental monitoring.
development of skills in teenagers including social and peer-resistance skills, development of behavioral norms, and positive peer affiliations
comparison groups included other interventions or no intervention
family-based prevention programs significantly reduced alcohol use in 9 of 12 trials
Reference - Cochrane Database Syst Rev 2011 Sep 7;(9):CD009308
community-based program for adolescents may reduce initiation of alcohol, drug, and tobacco use, but does not appear to decrease level of use in those who do not abstain (level 2 [mid-level] evidence)
based on cluster-randomized trial without intention-to-treat analysis
24 communities (population ≤ 50,000 each) were randomized to 1 of 2 interventions for fifth-grade public school students aged 10-14 years
community-based program ("Communities That Care") consisted of identification of risk factors for adolescent problem behaviors within individual communities through youth surveys followed by implementation of school-, family-, and community-based programs by community coalition for 5 years
control intervention consisted of distribution of data from youth surveys once every 2 years without further assistance
4,407 students in 5th grade were enrolled and 90.5% completed follow-up in 12th grade
all outcomes were self-reported
sustained abstinence defined as no initiation of use from 5th grade through 12th grade in students
comparing community-based program vs. control intervention
sustained abstinence from alcohol use in 32.2% vs. 23.3% (p < 0.05)
sustained abstinence from any drug use in 24.5% vs. 17.6% (p < 0.05)
sustained abstinence from tobacco use in 49.9% vs. 42.8% (p < 0.05)
no significant differences in cumulative 8-year incidence or in prevalence during past month or year in nonabstainers
Reference - JAMA Pediatr 2014 Feb;168(2):122 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost

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