Daniel E. Jonas, MD, MPH; James C. Garbutt, MD; Halle R. Amick, MSPH; Janice M. Brown, PhD; Kimberly A. Brownley, PhD; Carol L. Council, MSPH; Anthony J. Viera, MD, MPH; Tania M. Wilkins, MS; Cody J. Schwartz, MPH; Emily M. Richmond, MPH; John Yeatts, MPH; Tammeka Swinson Evans, MOP; Sally D. Wood, BA; Russell P. Harris, MD, MPH
Disclaimer: The views expressed in this article do not represent and should not be construed to represent a determination or policy of AHRQ or the U.S. Department of Health and Human Services.
Grant Support: By AHRQ, contract 290-2007-10056-I.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-3047.
Requests for Single Reprints: Daniel E. Jonas, MD, MPH, University of North Carolina at Chapel Hill, Department of Medicine, 5034 Old Clinic Building, CB 7110, Chapel Hill, NC 27599; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Jonas: University of North Carolina at Chapel Hill, Department of Medicine, 5034 Old Clinic Building, CB 7110, Chapel Hill, NC 27599.
Dr. Garbutt: University of North Carolina at Chapel Hill, Department of Psychiatry, CB 7160, Chapel Hill, NC 27599.
Ms. Amick, Ms. Wilkins, and Dr. Harris: Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Boulevard, CB 7590, Chapel Hill, NC 27599.
Dr. Brown: 6209 West Sugar Pine Trail, Tucson, AZ 85743.
Dr. Brownley: University of North Carolina at Chapel Hill, Department of Psychiatry, CB 7175, Chapel Hill, NC 27599.
Ms. Council and Ms. Evans: RTI International, 3040 Cornwallis Road, Box 12194, Research Triangle Park, NC 27709.
Dr. Viera: University of North Carolina School of Medicine, Department of Family Medicine, 590 Manning Drive, CB 7595, Chapel Hill, NC 27599.
Mr. Schwartz: University of North Carolina School of Medicine, 1001 Bondurant Hall, CB 9535, Chapel Hill, NC 27599.
Ms. Richmond: 229 Cherrywood Avenue, San Leandro, CA 94577.
Mr. Yeatts: 444 South Blount Street 326, Raleigh, NC 27601.
Ms. Wood: 403 Pritchard Avenue, Chapel Hill, NC 27516.
Author Contributions: Conception and design: D.E. Jonas, J.C. Garbutt, H.R. Amick, K.A. Brownley, C.L. Council, E.M. Richmond, R.P. Harris.
Analysis and interpretation of the data: D.E. Jonas, J.C. Garbutt, H.R. Amick, J.M. Brown, K.A. Brownley, C.L. Council, A.J. Viera, T.M. Wilkins, C.J. Schwartz, E.M. Richmond, J. Yeatts, T.S. Evans, S.D. Wood, R.P. Harris.
Drafting of the article: D.E. Jonas, J.C. Garbutt, H.R. Amick, J.M. Brown, K.A. Brownley, C.L. Council, R.P. Harris.
Critical revision of the article for important intellectual content: D.E. Jonas, J.C. Garbutt, H.R. Amick, C.L. Council, A.J. Viera, R.P. Harris.
Final approval of the article: D.E. Jonas, H.R. Amick, J.M. Brown, A.J. Viera, J. Yeatts, R.P. Harris.
Provision of study materials or patients: D.E. Jonas.
Statistical expertise: D.E. Jonas.
Obtaining of funding: D.E. Jonas.
Administrative, technical, or logistic support: H.R. Amick.
Collection and assembly of data: D.E. Jonas, H.R. Amick, K.A. Brownley, C.L. Council, A.J. Viera, C.J. Schwartz, E.M. Richmond, J. Yeatts, T.S. Evans, S.D. Wood.
Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL, et al. Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012;157:645-654. doi: 10.7326/0003-4819-157-9-201211060-00544
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Published: Ann Intern Med. 2012;157(9):645-654.
Alcohol misuse, which includes the full spectrum from risky drinking to alcohol dependence, is a leading cause of preventable death in the United States.
To evaluate the benefits and harms of behavioral counseling interventions for adolescents and adults who misuse alcohol.
MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and reference lists of published literature (January 1985 through January 2012, limited to English-language articles).
Controlled trials at least 6 months' duration that enrolled persons with alcohol misuse identified by screening in primary care settings and evaluated behavioral counseling interventions.
One reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings and graded the strength of the evidence.
The 23 included trials generally excluded persons with alcohol dependence. The best evidence was for brief (10- to 15-minute) multicontact interventions. Among adults receiving behavioral interventions, consumption decreased by 3.6 drinks per week from baseline (weighted mean difference, 3.6 drinks/wk [95% CI, 2.4 to 4.8 drinks/wk]; 10 trials; 4332 participants), 12% fewer adults reported heavy drinking episodes (risk difference, 0.12 [CI, 0.07 to 0.16]; 7 trials; 2737 participants), and 11% more adults reported drinking less than the recommended limits (risk difference, 0.11 [CI, 0.08 to 0.13]; 9 trials; 5973 participants) over 12 months compared with control participants (moderate strength of evidence). Evidence was insufficient to draw conclusions about accidents, injuries, or alcohol-related liver problems. Trials enrolling young adults or college students showed reduced consumption and fewer heavy drinking episodes (moderate strength of evidence). Little or no evidence of harms was found.
Results may be biased to the null because the behavior of control participants could have been affected by alcohol misuse assessments. In addition, evidence is probably inapplicable to persons with alcohol dependence and selective reporting may have occurred.
Behavioral counseling interventions improve behavioral outcomes for adults with risky drinking.
Agency for Healthcare Research and Quality.
Definitions of the Spectrum of Alcohol Misuse
Appendix Table 1.
Key Questions for This Systematic Review
Analytic framework for screening, behavioral counseling, and referral in primary care to reduce alcohol misuse.
KQ = key question.
Appendix Table 2.
Definitions of the Grades of Overall Strength of Evidence
Summary of evidence search and selection.
Appendix Table 3.
Characteristics of Included Trials Comparing Behavioral Counseling Interventions With Control Groups
Appendix Table 4.
Description of Behavioral Counseling Interventions, by Intervention Intensity
Effectiveness and Strength of Evidence of Behavioral Interventions Compared With Controls for Improving Intermediate Outcomes, by Population
Forest plots for alcohol consumption, heavy drinking, and achieving recommended drinking limits for groups receiving behavioral counseling interventions compared with control groups.
BCI = behavioral counseling intervention; ELM = Early Lifestyle Modification; SIP = Screening and Intervention in Primary Care; TrEAT = Trial for Early Alcohol Treatment; WHO BISG = World Health Organization Brief Intervention Study Group.
Effectiveness and Strength of Evidence of Behavioral Interventions Compared With Controls for Improving Health, Utilization, and Other Outcomes, by Population
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Richard Saitz, MD
March 20, 2013
Conflict of Interest:
Dr. Saitz is employed by for Boston University as a Professor focused on alcohol-related research and education. He provides clinical services at Boston Medical Center (BMC), an institution that cares for patients with unhealthy alcohol use. He is supported via BMC by grants for alcohol-related research and consults for NIH-supported alcohol-related studies at other academic institutions in the US and abroad. He has consulted for National Development and Research Institutes and Medical Directions Inc. on alcohol-related research and education studies. He has been compensated for grand rounds at academic institutions and plenary lectures at professional societies related to unhealthy alcohol use and has provided expert opinion on legal cases involving identification and management of unhealthy alcohol use. He was a member in 2011 of the Technical Expert Panel for the Agency for Healthcare Research and Quality (AHRQ) that provided input for the report commented on here.
Alcohol "Misuse" is a misuse of "misuse"
Jonas et al's excellent review missed an opportunity to clarify terminology. We screen for "unhealthy alcohol use." “Misuse” is confusing. Some believe it means risky use without dependence. Others (e.g. Jonas et al, which ironically references an article titled "unhealthy alcohol use" to define "misuse")(1) use it to mean the spectrum that includes dependence. In fact the annals.org home page demonstrates how easy it is to confuse—“counseling patients about alcohol misuse reduces unhealthy drinking” (accessed 9/25/2012). Actually, counseling was not beneficial for misuse or unhealthy use; it only affected drinking among those with risky use, not the full spectrum of “misuse” or “unhealthy use” a key point made by Jonas et al.
In addition to the lack of clarity, it is problematic to refer to people who have a brain disease (those with chronic dependence) as "misusing" alcohol, as if it were an accident or misjudgment. Those who use risky amounts also may not be “misusing;” like people may choose to eat a cheeseburger, they may be using alcohol after considering the risks. “Misuse” distances alcohol-related conditions from how we discuss other health risks. We don’t talk of cheeseburger misuse or heroin misuse.
Addiction patients and clinicians are outside of mainstream health care, much to their detriment, and "misuse" doesn't help integrate care. "Unhealthy" encompasses all use that affects health adversely, and calls it like it is. Some may worry “unhealthy” implies the existence of healthy use, but it doesn’t. A similar objection could be raised for “misuse,” which could imply there is a correct way to use alcohol.
The Centers for Medicare and Medicaid Services incentivizes screening for "unhealthy alcohol use" in its Physician Quality Reporting Initiative. The Centers for Disease Control has published a guide for screening and brief intervention for "unhealthy alcohol use" (2). National Institutes of Health publications call it "unhealthy alcohol use" (3), and numerous peer-reviewed papers have done so.
How we communicate matters—for clinical reasons, but perhaps even more so, outside of medicine in policy circles and in the general public. "Misuse" is confusing, sends the wrong messages both about use of risky amounts of alcohol and about dependence, and distances alcohol, one of the leading causes of preventable death and disability in the world, from health and healthcare. Calling it what it is--unhealthy--is likely to contribute to the best approaches for patients, clinicians and the general public.
Tobacco, Alcohol, and Other Substance Abuse, Prevention/Screening.
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