Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force

Daniel E. Jonas; James C. Garbutt; Halle R. Amick; Janice M. Brown; Kimberly A. Brownley; Carol L. Council; Anthony J. Viera; Tania M. Wilkins; Cody J. Schwartz; Emily M. Richmond; John Yeatts; Tammeka Swinson Evans; Sally D. Wood; Russell P. Harris

doi:10.7326/0003-4819-157-9-201211060-00544

Reviews |6 November 2012

Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force Free

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

Article, Author, and Disclosure Information

This article was published at www.annals.org on 25 September 2012.

From University of North Carolina at Chapel Hill and Cecil G. Sheps Center for Health Services Research, Chapel Hill, and Research Triangle Institute International, Research Triangle Park, North Carolina.
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, daniel_jonas@med.unc.edu.
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.

Abstract

Background:

Alcohol misuse, which includes the full spectrum from risky drinking to alcohol dependence, is a leading cause of preventable death in the United States.

Purpose:

To evaluate the benefits and harms of behavioral counseling interventions for adolescents and adults who misuse alcohol.

Data Sources:

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).

Study Selection:

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.

Data Extraction:

One reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings and graded the strength of the evidence.

Data Synthesis:

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.

Limitations:

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.

Conclusion:

Behavioral counseling interventions improve behavioral outcomes for adults with risky drinking.

Primary Funding Source:

Agency for Healthcare Research and Quality.

Alcohol misuse, which includes the full spectrum from risky or hazardous drinking to alcohol dependence (1–3), is associated with numerous health and social problems and more than 85 000 deaths per year in the United States (4, 5). Alcohol misuse is the third leading cause of preventable death in the United States, after tobacco use and being overweight (6). It contributes to hypertension, cirrhosis, gastritis, gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, suicide, injury, and violence (7–9). The definitions of the spectrum of alcohol misuse (that is, unhealthy alcohol use [1]) continue to evolve. For this review, we use the definitions in Table 1 (5, 10–12).

Table 1.

Definitions of the Spectrum of Alcohol Misuse

Table 1.

About 30% of the U.S. population misuse alcohol, with most engaging in what is considered risky drinking (1). Recent U.S.-based data (13) revealed that 21.3% of primary care patients reported risky drinking.

Cross-sectional and cohort studies have consistently related high average alcohol consumption and heavy per-occasion use to short- or long-term health consequences (14, 15). A meta-analysis examining the association between all-cause mortality and average alcohol consumption (16) found that men who drank an average of at least 4 drinks per day and women who drank an average of at least 2 drinks per day had increased mortality relative to nondrinkers. The National Institute on Alcohol Abuse and Alcoholism has proposed guidelines (17) to limit the risks for drinking-related consequences. The maximum recommended consumption is 3 or fewer standard drinks per day (≤7 drinks/wk) for adult women and anyone older than 65 years, and 4 or fewer standard drinks per day (≤14 drinks/week) for men (15, 17, 18). These guidelines do not apply to persons for whom alcohol intake is contraindicated, such as pregnant women, persons with alcohol dependence or medical conditions that can be worsened by drinking, or those receiving medications that interact with alcohol.

Behavioral counseling interventions include the range of personal counseling and related behavior-change interventions that are used to help patients change health-related behaviors (19). “Counseling” here denotes a cooperative method of work that demands active participation from both patient and clinician and aims to facilitate the patient's independent initiative (19). The goal of behavioral interventions for alcohol misuse is to eliminate risky drinking practices (for example, by encouraging fewer drinks per occasion or not drinking before driving) rather than to achieve abstinence.

For the Effective Health Care Program of the Agency for Healthcare Research and Quality (AHRQ) and to assist the U.S. Preventive Services Task Force (USPSTF) in updating its 2004 recommendation statement (20), we conducted a systematic review and meta-analysis of the effectiveness of screening followed by behavioral counseling, with or without referral, for alcohol misuse in primary care settings (21). The full report (21) addressed 7 questions (Appendix Table 1).

Appendix Table 1.

Key Questions for This Systematic Review

Appendix Table 1.

Methods

We developed and followed a standard protocol. A technical report that details methods and includes search strategies and additional evidence tables is available at www.effectivehealthcare.ahrq.gov/reports/final.cfm.

Key Questions and Analytic Framework

The USPSTF and the AHRQ determined the focus of this review. Investigators developed key questions and created an analytic framework that incorporated the key questions and outlined patient populations, interventions, comparators, outcomes (including adverse effects), and settings (Appendix Figure 1). This report focuses on the key questions related to benefits and harms of behavioral interventions.

Appendix Figure 1.

Analytic framework for screening, behavioral counseling, and referral in primary care to reduce alcohol misuse.

KQ = key question.

Data Sources and Searches

We searched MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, and the International Pharmaceutical Abstracts from 1 January 1985 to 31 January 2012, limited to English-language articles. The start date was selected on the basis of the earliest publication date found in previous reviews and expert opinion. We used Medical Subject Headings as search terms when available and keywords when appropriate, focusing on terms to describe relevant populations, screening, and behavioral interventions.

Study Selection

We developed inclusion and exclusion criteria with respect to populations, interventions, comparators, outcomes, timing, settings, and study designs (22, 23). For the question related to behavioral interventions, we included randomized, controlled trials of at least 6 months' duration that enrolled adults or adolescents with alcohol misuse identified by screening in primary care settings and that evaluated whether a counseling intervention improved behavioral or health outcomes.

Two investigators independently reviewed titles and abstracts, and then another 2 investigators independently reviewed the full text of all articles marked for possible inclusion during the initial review to determine final inclusion or exclusion. Disagreements were resolved with an experienced team member.

Data Extraction and Quality Assessment

We designed and used structured forms to extract pertinent information from each article, including information about the methods and populations, interventions, comparators, outcomes, timing, settings, and study designs. All data extractions were reviewed for completeness and accuracy by a second team member.

We assessed the quality (internal validity) of studies using predefined criteria based on those developed by the USPSTF (ratings of good, fair, or poor) (24) and the University of York Centre for Reviews and Dissemination (25). These included assessment of the adequacy of randomization, allocation concealment, similarity of groups at baseline, masking, attrition, and whether intention-to-treat analysis was used. Two independent reviewers assigned quality ratings for each study. Disagreements were resolved by an experienced member of the team.

Data Synthesis and Analysis

We stratified evidence by population (adults, older adults, young adults or college students, and pregnant women). Quantitative analyses were conducted of outcomes reported by a sufficient number of studies that were homogeneous enough to justify combining their results. We used random-effects models. For the outcome of alcohol consumption, the effect measure was mean difference between the intervention and control groups for change from baseline in drinks per week. The percentages of patients who had episodes of heavy drinking and those who achieved recommended drinking limits were compared (between intervention and control groups) with a risk difference. Because follow-up periods varied, the analysis for all-cause mortality was based on deaths per person-year and the comparison between intervention and control groups was calculated as a risk ratio. Analyses were conducted by using Comprehensive Meta Analysis, version 2.2.055 (BioStat, Englewood, New Jersey).

We used subgroup analyses to explore whether results differed by intensity, sex, country, deliverer of the intervention, or setting. The chi-square and I² statistics were calculated to assess heterogeneity in effects between studies (26, 27). When quantitative analyses were not appropriate (for example, because of heterogeneity, insufficient number of similar studies, or insufficient or varied outcome reporting), we synthesized the data qualitatively.

To assess the differential effects of using more or less time and single or multiple contacts, we grouped interventions by intensity of counseling, as measured by the duration and number of contacts: very brief (≤5 minutes, single-contact), brief (6 to 15 minutes, single-contact), extended (>15 minutes, single-contact), brief multicontact (each contact ≤15 minutes), or extended multicontact (some contacts >15 minutes).

We then graded the strength of evidence (SOE) as high, moderate, low, or insufficient on the basis of the guidance established for the Evidence-based Practice Center Program (Appendix Table 2) (28). Two reviewers assessed each domain for each key outcome, and differences were resolved by consensus.

Appendix Table 2.

Definitions of the Grades of Overall Strength of Evidence

Appendix Table 2.

Role of the Funding Source

This review was funded by AHRQ. Staff of AHRQ and members of the USPSTF participated in developing the scope of the work and reviewed draft manuscripts. Approval from AHRQ for copyright assertion was required before the manuscript could be submitted for publication, but the authors are solely responsible for the content and the decision to submit it for publication.

Results

We included 38 articles reporting on 23 randomized, controlled trials (Appendix Figure 2). Sample sizes ranged from 72 to 1559, and study durations ranged from 6 to 48 months (Appendix Table 3). Eleven studies were done solely in the United States, 2 focused on older adults, 5 focused on young adults or college students, and 1 enrolled pregnant women. We identified no studies of adolescents.

Appendix Figure 2.

Summary of evidence search and selection.

Appendix Table 3.

Characteristics of Included Trials Comparing Behavioral Counseling Interventions With Control Groups

Appendix Table 3.

Fourteen of the interventions (29–50) were delivered by a primary care physician alone or with a health educator or nurse. Three (51–54) were delivered by a nurse or physician assistant, 1 by a psychologist (55–57), 2 by a researcher (58–62), and 1 by unspecified interventionists (63). Two interventions in college students (64–66) were conducted via a computer. Most trials tested brief multicontact interventions (31–34, 42, 46, 50, 51, 53, 64, 65) or brief interventions (29, 49, 52, 58, 60, 62–66); fewer tested very brief (45, 63), extended (30), or extended multicontact interventions (38, 45, 48, 55, 60). Interventions were heterogeneous and included various counseling approaches, such as brief advice, feedback, or motivational interviews, and cognitive behavioral strategies, such as self-completed action plans, written health education or self-help materials, drinking diaries, or problem-solving exercises to complete at home (Appendix Table 4). Most comparator groups received screening or assessment followed by usual care or by provision of a general health pamphlet. A few studies included additional components in comparator groups that could have biased results toward the null, such as recording screening or assessment results on the chart (45) or forwarding them to physicians (60), advice from nurses on reducing drinking and a leaflet with benchmark alcohol guides (52), a pamphlet on the health effects of alcohol consumption (64–66), or a booklet about preventing alcohol problems (48). We summarize the main findings by population and outcome and report the SOE for each.

Appendix Table 4.

Description of Behavioral Counseling Interventions, by Intervention Intensity

Appendix Table 4.

Screening

We found no studies meeting inclusion criteria that randomly assigned participants, practices, or providers to screening and a comparator (no studies addressing questions 1 or 3) (Appendix Table 1). We found adequate evidence that several screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity (21). The full technical report includes additional details about the accuracy of screening tests.

Effectiveness for Improving Intermediate Outcomes

Table 2 summarizes the results of meta-analyses for consumption, heavy drinking, and recommended drinking limits, by population. The Figure shows the forest plots for 12-month outcomes from our meta-analyses for adults. Overall, evidence supports the effectiveness of behavioral interventions for improving several intermediate outcomes for adults, older adults, and young adults or college students. For pregnant women, the included study (250 participants) (30) did not provide evidence of effectiveness for improving intermediate outcomes over 6 months or longer (low or insufficient SOE, depending on the outcome). Subgroup analyses identified no significant differences between men and women. Brief multicontact interventions had the best evidence of effectiveness across populations and outcomes and had follow-up data spanning several years. Meta-analyses of studies in adults found very brief and brief single-contact interventions to be ineffective for some outcomes and less effective than brief multicontact interventions for others.

Table 2.

Effectiveness and Strength of Evidence of Behavioral Interventions Compared With Controls for Improving Intermediate Outcomes, by Population

Table 2.

Figure.

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 for Reducing Morbidity, Reducing Mortality, or Changing Other Outcomes

Table 3 summarizes results, by population. Our meta-analyses found no statistically significant reduction in all-cause mortality for adults (rate ratio, 0.64 [95% CI, 0.24 to 1.7]; 4 trials) or for all age groups combined (rate ratio, 0.52 [CI, 0.22 to 1.2]; 6 trials). Point estimates trended toward favoring interventions, but few studies reported mortality and few long-term data were available. No studies that enrolled pregnant women and reported these outcomes were found (insufficient SOE).

Table 3.

Effectiveness and Strength of Evidence of Behavioral Interventions Compared With Controls for Improving Health, Utilization, and Other Outcomes, by Population

Table 3.

Potential Adverse Effects

We found no evidence of direct harms, aside from opportunity costs associated with interventions, which ranged from 5 minutes to 2 hours dispersed over several in-person or telephone visits (moderate SOE). We searched for evidence of potential adverse effects, such as illegal substance use, increased smoking, anxiety, stigma, labeling, discrimination, or interference with the physician–patient relationship. We found no evidence for most of these potential harms and very limited evidence reporting no difference between groups for smoking rates and anxiety (low SOE). Other than the results for opportunity costs, our results are limited by the few trials that reported any information; 5 of 23 reported smoking (29, 33, 34, 39, 41, 49, 50), and 2 reported anxiety (29, 49).

Health Care System Influences

Where the study was conducted (United States vs. non–United States) had no impact on the effectiveness of interventions for consumption outcomes. Data showed a tendency toward greater reduction in consumption for interventions delivered in academic- or research-oriented settings than for those delivered in community-based settings (weighted mean difference, −5.0 drinks/wk [CI, −7.6 to −2.5 drinks/wk] vs. −3.2 drinks/wk [CI, −4.3 to −2.2 drinks/wk]; 3 vs. 7 trials). Interventions delivered mostly by primary care providers showed a tendency toward greater reduction in consumption than did those delivered primarily by research personnel (weighted mean difference, −4.0 drinks/wk [CI, −5.4 to −2.6 drinks/wk] vs. −3.0 drinks/wk [CI, −5.0 to −1.0 drinks/wk]; 7 vs. 2 trials). Our consumption meta-analysis included only 1 intervention delivered by a nurse (52), and the reduction was not statistically significant in that study (weighted mean difference, −0.2 drinks/wk [CI, −8.9 to 8.6 drinks/wk]). Two other studies, each of which provided insufficient data for our consumption meta-analysis, reported benefits of interventions delivered primarily by nurses (51) or by nurses and physician assistants (53) for some consumption outcomes. In addition, 2 interventions conducted by computer reported some evidence of effectiveness for reduced consumption in college students (64–66).

Discussion

We found no studies that directly addressed our overarching question (key question 1)—no studies randomly assigned patients, practices, or providers to screening and comparator groups and subsequently provided interventions for those with positive screening results. All of the included studies randomly assigned patients after they had received positive screening results.

We found that behavioral counseling interventions improved drinking behavior outcomes (moderate SOE) and reduced hospital days (low SOE) for adults with risky drinking. For most health outcomes, available evidence either found no difference between intervention and control groups, such as for mortality (low SOE), or was insufficient to draw conclusions, such as for alcohol-related liver problems (insufficient SOE). Long-term outcomes from 2 studies (33, 35–37, 39, 42, 43) revealed that participants in the intervention groups maintained reductions in consumption or continued to reduce consumption, but differences between intervention and control groups were no longer statistically significant by 48 months. Studies identified delayed reduction in consumption in control groups that could reflect the natural history of alcohol consumption, the cumulative effect of follow-up with the health care system, differential attrition (if more participants lost to follow-up in the control group were risky drinkers), or (late) regression to the mean.

The evidence for effectiveness in adults is strongest for brief multicontact interventions. The effect sizes for these interventions were greater than those for other intensities (although CIs often overlapped). In addition, the best studies show that the effect of brief multicontact interventions remains for several years (35, 36, 43) and also show improvement for some utilization outcomes, such as fewer hospital days (35, 36) and costs (benefit–cost ratio of 39:1 over 48 months [CI, 5.4 to 72.5]) (36).

The brief multicontact interventions generally lasted 10 to 15 minutes per contact. All of the brief multicontact interventions in our meta-analyses of behavioral outcomes at 12 months were delivered by primary care providers, sometimes with additional intervention from a nurse or health educator. For example, the intervention in Project TrEAT (Trial for Early Alcohol Treatment) (33) included two 15-minute visits with a primary care provider 1 month apart and two 5-minute follow-up phone calls from a nurse 2 weeks after each visit. The intervention also included feedback about health behaviors, a review of problem drinking prevalence, a list of the adverse effects of alcohol, a worksheet on drinking cues, a drinking agreement or prescription, and drinking diary cards. Of note, 2 studies of brief multicontact interventions in adults, both of which provided insufficient data for our meta-analyses, reported benefits of interventions delivered primarily by nurses (51) or by nurses and physician assistants (53) for some consumption outcomes.

Evidence suggests that very brief interventions (up to 5 minutes, single-contact) and brief interventions (up to 15 minutes, single-contact) are less effective or ineffective, depending on the outcome. Although extended multicontact interventions seem to be effective for improving intermediate outcomes, we found no evidence that they are more effective than brief multicontact interventions.

The only included study that enrolled pregnant women (250 participants) (30) found no difference in reduced consumption between groups but did find higher rates of continued abstinence among women who were abstinent before the assessment in the intervention group than among those in the control group. Our searches identified other studies focusing on pregnant women that did not meet our inclusion criteria (67–84). Several took place in such settings as jails or specialized drug and alcohol treatment centers (75), and others lacked a control group or followed participants for fewer than 6 months (73, 84). Several of these studies reported benefits of interventions, including reduced consumption (73, 84), reduced risk for an alcohol-exposed pregnancy (75), higher rates of abstinence (79), and better fetal and newborn outcomes (higher birth weights and lengths and reduced fetal mortality rates [79]).

We have described several categories of alcohol misuse (such as risky or hazardous use and alcohol dependence). These categories are not all discrete (an individual may meet the definition for more than one). Included trials generally enrolled participants with risky or hazardous drinking, but the trials used varying terminology to describe the populations and often enrolled heterogeneous samples. Nevertheless, most investigators excluded participants with alcohol dependence or constructed their inclusion and exclusion criteria to substantially limit the number of such participants. Our best assessment is that our overall findings apply to risky or hazardous drinkers but not to persons with alcohol dependence. It is uncertain whether our findings apply to harmful drinkers or persons with alcohol abuse.

All interventions required support systems to provide screening; screening-related assessment; and in some cases, provider prompting. Screening assessments were often multistep processes that included interviews with research personnel that lasted up to 30 minutes. Less time would be required for screening and screening-related assessments in primary care practice. We estimate that 5 to 10 minutes would be required for persons who had positive screening results, with most of the time used to assess whether such persons have alcohol abuse or dependence (and should probably be referred for specialized treatment) as opposed to risky or hazardous drinking (for which behavioral counseling interventions in primary care may be effective). Nevertheless, support systems are probably required for effective screening and intervention. In addition, most interventions required training providers or staff.

It is unclear whether our findings apply to persons with certain comorbid conditions, and some researchers have suggested that brief behavioral interventions may be ineffective or less effective in people with comorbid psychiatric conditions. A subgroup analysis from a German study (56) found that brief interventions did not reduce drinking among 88 participants with comorbid anxiety or depression. Although most trials in our review did not exclude persons with depression, anxiety, or chronic pain, it is unclear how many participants with these conditions were included in most trials.

A previous systematic review (85) found no evidence of efficacy for brief behavioral interventions in patients with alcohol dependence in primary care settings. Our review also found no such evidence. Included studies that enrolled more than 10% of participants with alcohol dependence reported interventions to be ineffective or less effective than studies that did not enroll alcohol-dependent participants.

Screening for alcohol misuse will inevitably identify some alcohol-dependent individuals; thus, providers and those making recommendations need information about whether effective interventions are available for alcohol dependence. If complete abstinence is used as an outcome, 15% to 35% of patients have been reported to achieve 1 year of sobriety after such treatment approaches (86) as pharmacotherapy, motivational enhancement therapy, cognitive behavioral therapy, 12-step facilitation, and therapy at alcoholism-treatment centers. Similar sobriety outcomes at 3 to 5 years or longer have been reported (9).

Our review has limitations. First, the scope of our review was limited to primary care settings. Second, most evidence involved self-report of alcohol use. Investigators in some trials verified self-reported use with other persons (such as family members). Self-report of alcohol use has been found to be accurate if collected carefully (87, 88). Third, the assessments conducted in the included trials could have concealed benefits of interventions (and biased results toward the null) by causing behavior changes. Control participants generally reduced alcohol consumption. Possible explanations include increased awareness of drinking, discussions with their provider about drinking that were prompted by the screening questions, receipt of some minimal intervention (control groups in the included studies often received some printed educational materials), or regression to the mean. A recent systematic review (89) concluded that answering questions on drinking in brief intervention trials seems to alter subsequent self-reported behavior, potentially generating bias by exposing nonintervention control groups to an integral component of the intervention. Finally, publication bias and selective reporting may be present.

In conclusion, behavioral counseling interventions improve intermediate outcomes, such as alcohol consumption, heavy drinking episodes, and drinking above recommended amounts (moderate SOE) and may reduce hospital days (low SOE) for adults with risky or hazardous drinking. For most health outcomes, available evidence found no difference between intervention and control groups, such as for mortality (low SOE), or was insufficient to draw conclusions about the effectiveness of behavioral interventions, such as for alcohol-related accidents or quality of life (insufficient SOE). Brief multicontact interventions (about 10 to 15 minutes per contact) have the best evidence of effectiveness for adults.

References

Saitz
R
.
Clinical practice. Unhealthy alcohol use.
N Engl J Med
2005
352
596-607
PubMed
CrossRef

PubMed
U.S. Department of Veterans Affairs. AUDIT-C Frequently Asked Questions. Washington, DC: U.S. Department of Veterans Affairs; 2010. Accessed at www.queri.research.va.gov/tools/alcohol-misuse/alcohol-faqs.cfm on 8 June 2012.
Whitlock
EP
,
Green
CA
,
Polen
MR
.
Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use. Systematic Evidence Review no. 30.
Rockville, MD
Agency for Healthcare Research and Quality
2004
Mokdad
AH
,
Marks
JS
,
Stroup
DF
,
Gerberding
JL
.
Actual causes of death in the United States, 2000.
JAMA
2004
291
1238-45
PubMed
PubMed
Whitlock
EP
,
Polen
MR
,
Green
CA
,
Orleans
T
,
Klein
J
.
U.S. Preventive Services Task Force
Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force.
Ann Intern Med
2004
140
557-68
PubMed
PubMed
CrossRef
Centers for Disease Control and Prevention. FastStats: Alcohol Use. Atlanta: Centers for Disease Control and Prevention; 2012. Accessed at www.cdc.gov/nchs/fastats/alcohol.htm on 8 June 2012.
Cherpitel
CJ
,
Ye
Y
.
Alcohol-attributable fraction for injury in the U.S. general population: data from the 2005 National Alcohol Survey.
J Stud Alcohol Drugs
2008
69
535-8
PubMed
PubMed
Corrao
G
,
Bagnardi
V
,
Zambon
A
,
La Vecchia
C
.
A meta-analysis of alcohol consumption and the risk of 15 diseases.
Prev Med
2004
38
613-9
PubMed
CrossRef

PubMed
Schuckit
MA
.
Alcohol-use disorders.
Lancet
2009
373
492-501
PubMed
PubMed
Isaac
M
,
Janca
A
,
Sartorius
N
.
ICD-10 Symptom Glossary for Mental Disorders.
Geneva
World Health Organization
1994
Janca
A
,
Ustun
TB
,
van Drimmelen
J
,
Dittmann
V
,
Isaac
M
.
ICD-10 Symptom Checklist for Mental Disorders, version 1.1.
Geneva
World Health Organization
1994
American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Washington, DC
American Psychiatric Assoc
1994
Vinson
DC
,
Manning
BK
,
Galliher
JM
,
Dickinson
LM
,
Pace
WD
,
Turner
BJ
.
Alcohol and sleep problems in primary care patients: a report from the AAFP National Research Network.
Ann Fam Med
2010
8
484-92
PubMed
CrossRef

PubMed
Bondy
SJ
,
Rehm
J
,
Ashley
MJ
,
Walsh
G
,
Single
E
,
Room
R
.
Low-risk drinking guidelines: the scientific evidence.
Can J Public Health
1999
90
264-70
PubMed
PubMed
Shalala DE. 10th Special Report to the U.S. Congress on Alcohol and Health: Highlights From Current Research: From the Secretary of Health and Human Services. Washington, DC: U.S. Department of Health and Human Services; 2000. Accessed at http://pubs.niaaa.nih.gov/publications/10report/intro.pdf on 8 June 2012.
Holman
CD
,
English
DR
,
Milne
E
,
Winter
MG
.
Meta-analysis of alcohol and all-cause mortality: a validation of NHMRC recommendations.
Med J Aust
1996
164
141-5
PubMed
PubMed
National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. Updated 2005 ed. Washington, DC: U.S. Department of Health and Human Services; 2005. Accessed at http://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf on 8 June 2012.
Dawson
DA
,
Grant
BF
,
Li
TK
.
Quantifying the risks associated with exceeding recommended drinking limits.
Alcohol Clin Exp Res
2005
29
902-8
PubMed
PubMed
Whitlock
EP
,
Orleans
CT
,
Pender
N
,
Allan
J
.
Evaluating primary care behavioral counseling interventions: an evidence-based approach.
Am J Prev Med
2002
22
267-84
PubMed
CrossRef

PubMed
U.S. Preventive Services Task Force
Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement.
Ann Intern Med
2004
140
554-6
PubMed
PubMed
Jonas
DE
,
Garbutt
JC
,
Brown
JM
,
Amick
HR
,
Brownley
KA
,
Council
CL
.
et al
Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse. Comparative Effectiveness Review no. 64. AHRQ Publication no. 12-EHC055-EF.
Rockville, MD
Agency for Healthcare Research and Quality
2012
Counsell
C
.
Formulating questions and locating primary studies for inclusion in systematic reviews.
Ann Intern Med
1997
127
380-7
PubMed
PubMed
CrossRef
Agency for Healthcare Research and Quality
AHRQ EHCP Methods Guide for Comparative Effectiveness Reviews of Medical Interventions.
Rockville, MD
Agency for Healthcare Research and Quality
2010
Harris
RP
,
Helfand
M
,
Woolf
SH
,
Lohr
KN
,
Mulrow
CD
,
Teutsch
SM
.
et al
Methods Work Group
Third U.S. Preventive Services Task Force
Current methods of the US Preventive Services Task Force: a review of the process.
Am J Prev Med
2001
20
21-35
PubMed
CrossRef

PubMed
Centre for Reviews and Dissemination
Systematic Reviews: CRD's Guidance for Undertaking Reviews in Healthcare.
York, UK
Univ York
2009
Higgins
JP
,
Thompson
SG
.
Quantifying heterogeneity in a meta-analysis.
Stat Med
2002
21
1539-58
PubMed
CrossRef

PubMed
Higgins
JP
,
Thompson
SG
,
Deeks
JJ
,
Altman
DG
.
Measuring inconsistency in meta-analyses.
BMJ
2003
327
557-60
PubMed
CrossRef

PubMed
Owens
DK
,
Lohr
KN
,
Atkins
D
,
Treadwell
JR
,
Reston
JT
,
Bass
EB
.
et al
AHRQ series paper 5: grading the strength of a body of evidence when comparing medical interventions—Agency for Healthcare Research and Quality and the Effective Health-Care Program.
J Clin Epidemiol
2010
63
513-23
PubMed
CrossRef

PubMed
Anderson
P
,
Scott
E
.
The effect of general practitioners' advice to heavy drinking men.
Br J Addict
1992
87
891-900
PubMed
CrossRef

PubMed
Chang
G
,
Wilkins-Haug
L
,
Berman
S
,
Goetz
MA
.
Brief intervention for alcohol use in pregnancy: a randomized trial.
Addiction
1999
94
1499-508
PubMed
CrossRef

PubMed
Curry
SJ
,
Ludman
EJ
,
Grothaus
LC
,
Donovan
D
,
Kim
E
.
A randomized trial of a brief primary-care–based intervention for reducing at-risk drinking practices.
Health Psychol
2003
22
156-65
PubMed
CrossRef

PubMed
Fleming
MF
,
Balousek
SL
,
Grossberg
PM
,
Mundt
MP
,
Brown
D
,
Wiegel
JR
.
et al
Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics.
J Stud Alcohol Drugs
2010
71
23-31
PubMed
PubMed
Fleming
MF
,
Barry
KL
,
Manwell
LB
,
Johnson
K
,
London
R
.
Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices.
JAMA
1997
277
1039-45
PubMed
CrossRef

PubMed
Fleming
MF
,
Manwell
LB
,
Barry
KL
,
Adams
W
,
Stauffacher
EA
.
Brief physician advice for alcohol problems in older adults: a randomized community-based trial.
J Fam Pract
1999
48
378-84
PubMed
PubMed
Fleming
MF
,
Mundt
MP
,
French
MT
,
Manwell
LB
,
Stauffacher
EA
,
Barry
KL
.
Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings.
Med Care
2000
38
7-18
PubMed
CrossRef

PubMed
Fleming
MF
,
Mundt
MP
,
French
MT
,
Manwell
LB
,
Stauffacher
EA
,
Barry
KL
.
Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis.
Alcohol Clin Exp Res
2002
26
36-43
PubMed
CrossRef

PubMed
Grossberg
PM
,
Brown
DD
,
Fleming
MF
.
Brief physician advice for high-risk drinking among young adults.
Ann Fam Med
2004
2
474-80
PubMed
CrossRef

PubMed
Lin
JC
,
Karno
MP
,
Tang
L
,
Barry
KL
,
Blow
FC
,
Davis
JW
.
et al
Do health educator telephone calls reduce at-risk drinking among older adults in primary care?
J Gen Intern Med
2010
25
334-9
PubMed
PubMed
Manwell
LB
,
Fleming
MF
,
Mundt
MP
,
Stauffacher
EA
,
Barry
KL
.
Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial.
Alcohol Clin Exp Res
2000
24
1517-24
PubMed
CrossRef

PubMed
Moore
AA
,
Blow
FC
,
Hoffing
M
,
Welgreen
S
,
Davis
JW
,
Lin
JC
.
et al
Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial.
Addiction
2011
106
111-20
PubMed
CrossRef

PubMed
Mundt
MP
,
French
MT
,
Roebuck
MC
,
Manwell
LB
,
Barry
KL
.
Brief physician advice for problem drinking among older adults: an economic analysis of costs and benefits.
J Stud Alcohol
2005
66
389-94
PubMed
PubMed
Ockene
JK
,
Adams
A
,
Hurley
TG
,
Wheeler
EV
,
Hebert
JR
.
Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work?
Arch Intern Med
1999
159
2198-205
PubMed
PubMed
Ockene
JK
,
Reed
GW
,
Reiff-Hekking
S
.
Brief patient-centered clinician-delivered counseling for high-risk drinking: 4-year results.
Ann Behav Med
2009
37
335-42
PubMed
CrossRef

PubMed
Reiff-Hekking
S
,
Ockene
JK
,
Hurley
TG
,
Reed
GW
.
Brief physician and nurse practitioner-delivered counseling for high-risk drinking. Results at 12-month follow-up.
J Gen Intern Med
2005
20
7-13
PubMed
CrossRef

PubMed
Richmond
R
,
Heather
N
,
Wodak
A
,
Kehoe
L
,
Webster
I
.
Controlled evaluation of a general practice-based brief intervention for excessive drinking.
Addiction
1995
90
119-32
PubMed
CrossRef

PubMed
Rubio
G
,
Jiménez-Arriero
MA
,
Martínez
I
,
Ponce
G
,
Palomo
T
.
Efficacy of physician-delivered brief counseling intervention for binge drinkers.
Am J Med
2010
123
72-8
PubMed
CrossRef

PubMed
Saitz
R
,
Horton
NJ
,
Sullivan
LM
,
Moskowitz
MA
,
Samet
JH
.
Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The Screening and Intervention in Primary Care (SIP) study.
Ann Intern Med
2003
138
372-82
PubMed
PubMed
CrossRef
Schaus
JF
,
Sole
ML
,
McCoy
TP
,
Mullett
N
,
O'Brien
MC
.
Alcohol screening and brief intervention in a college student health center: a randomized controlled trial.
J Stud Alcohol Drugs Suppl
2009
131-41
PubMed
Scott
E
,
Anderson
P
.
Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption.
Drug Alcohol Rev
1991
10
313-21
PubMed
CrossRef

PubMed
Wallace
P
,
Cutler
S
,
Haines
A
.
Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption.
BMJ
1988
297
663-8
PubMed
PubMed
Fleming
MF
,
Lund
MR
,
Wilton
G
,
Landry
M
,
Scheets
D
.
The Healthy Moms Study: the efficacy of brief alcohol intervention in postpartum women.
Alcohol Clin Exp Res
2008
32
1600-6
PubMed
CrossRef

PubMed
Lock
CA
,
Kaner
E
,
Heather
N
,
Doughty
J
,
Crawshaw
A
,
McNamee
P
.
et al
Effectiveness of nurse-led brief alcohol intervention: a cluster randomized controlled trial.
J Adv Nurs
2006
54
426-39
PubMed
CrossRef

PubMed
Noknoy
S
,
Rangsin
R
,
Saengcharnchai
P
,
Tantibhaedhyangkul
U
,
McCambridge
J
.
RCT of effectiveness of motivational enhancement therapy delivered by nurses for hazardous drinkers in primary care units in Thailand.
Alcohol Alcohol
2010
45
263-70
PubMed
CrossRef

PubMed
Wilton
G
,
Moberg
DP
,
Fleming
MF
.
The effect of brief alcohol intervention on postpartum depression.
MCN Am J Matern Child Nurs
2009
34
297-302
PubMed
CrossRef

PubMed
Bischof
G
,
Grothues
JM
,
Reinhardt
S
,
Meyer
C
,
John
U
,
Rumpf
HJ
.
Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: a randomized controlled trial.
Drug Alcohol Depend
2008
93
244-51
PubMed
CrossRef

PubMed
Grothues
JM
,
Bischof
G
,
Reinhardt
S
,
Meyer
C
,
John
U
,
Rumpf
HJ
.
Effectiveness of brief alcohol interventions for general practice patients with problematic drinking behavior and comorbid anxiety or depressive disorders.
Drug Alcohol Depend
2008
94
214-20
PubMed
CrossRef

PubMed
Reinhardt
S
,
Bischof
G
,
Grothues
J
,
John
U
,
Meyer
C
,
Rumpf
HJ
.
Gender differences in the efficacy of brief interventions with a stepped care approach in general practice patients with alcohol-related disorders.
Alcohol Alcohol
2008
43
334-40
PubMed
CrossRef

PubMed
Freeborn
DK
,
Polen
MR
,
Hollis
JF
,
Senft
RA
.
Screening and brief intervention for hazardous drinking in an HMO: effects on medical care utilization.
J Behav Health Serv Res
2000
27
446-53
PubMed
CrossRef

PubMed
Gordon
AJ
,
Conigliaro
J
,
Maisto
SA
,
McNeil
M
,
Kraemer
KL
,
Kelley
ME
.
Comparison of consumption effects of brief interventions for hazardous drinking elderly.
Subst Use Misuse
2003
38
1017-35
PubMed
CrossRef

PubMed
Maisto
SA
,
Conigliaro
J
,
McNeil
M
,
Kraemer
K
,
Conigliaro
RL
,
Kelley
ME
.
Effects of two types of brief intervention and readiness to change on alcohol use in hazardous drinkers.
J Stud Alcohol
2001
62
605-14
PubMed
PubMed
Maisto
SA
,
Conigliaro
J
,
McNeil
M
,
Kraemer
K
,
Kelley
ME
.
The relationship between eligibility criteria for participation in alcohol brief intervention trials and other alcohol and health-related variables.
Am J Addict
2001
10
218-31
PubMed
PubMed
Senft
RA
,
Polen
MR
,
Freeborn
DK
,
Hollis
JF
.
Brief intervention in a primary care setting for hazardous drinkers.
Am J Prev Med
1997
13
464-70
PubMed
PubMed
WHO Brief Intervention Study Group
A cross-national trial of brief interventions with heavy drinkers.
Am J Public Health
1996
86
948-55
PubMed
PubMed
Kypri
K
,
Langley
JD
,
Saunders
JB
,
Cashell-Smith
ML
.
Assessment may conceal therapeutic benefit: findings from a randomized controlled trial for hazardous drinking.
Addiction
2007
102
62-70
PubMed
CrossRef

PubMed
Kypri
K
,
Langley
JD
,
Saunders
JB
,
Cashell-Smith
ML
,
Herbison
P
.
Randomized controlled trial of web-based alcohol screening and brief intervention in primary care.
Arch Intern Med
2008
168
530-6
PubMed
CrossRef

PubMed
Kypri
K
,
Saunders
JB
,
Williams
SM
,
McGee
RO
,
Langley
JD
,
Cashell-Smith
ML
.
et al
Web-based screening and brief intervention for hazardous drinking: a double-blind randomized controlled trial.
Addiction
2004
99
1410-7
PubMed
CrossRef

PubMed
Armstrong
MA
,
Kaskutas
LA
,
Witbrodt
J
,
Taillac
CJ
,
Hung
YY
,
Osejo
VM
.
et al
Using drink size to talk about drinking during pregnancy: a randomized clinical trial of Early Start Plus.
Soc Work Health Care
2009
48
90-103
PubMed
CrossRef

PubMed
Budd
KW
,
Ross-Alaolmolki
K
,
Zeller
RA
.
Two prenatal alcohol use screening instruments compared with a physiologic measure.
J Obstet Gynecol Neonatal Nurs
2000
29
129-36
PubMed
PubMed
Bull
LB
,
Kvigne
VL
,
Leonardson
GR
,
Lacina
L
,
Welty
TK
.
Validation of a self-administered questionnaire to screen for prenatal alcohol use in Northern Plains Indian women.
Am J Prev Med
1999
16
240-3
PubMed
CrossRef

PubMed
Chang
G
,
Goetz
MA
,
Wilkins-Haug
L
,
Berman
S
.
A brief intervention for prenatal alcohol use: an in-depth look.
J Subst Abuse Treat
2000
18
365-9
PubMed
CrossRef

PubMed
Chang
G
,
Goetz
MA
,
Wilkins-Haug
L
,
Berman
S
.
Identifying prenatal alcohol use: screening instruments versus clinical predictors.
Am J Addict
1999
8
87-93
PubMed
PubMed
Chang
G
,
Wilkins-Haug
L
,
Berman
S
,
Goetz
MA
,
Behr
H
,
Hiley
A
.
Alcohol use and pregnancy: improving identification.
Obstet Gynecol
1998
91
892-8
PubMed
CrossRef

PubMed
Chang
G
,
McNamara
TK
,
Orav
EJ
,
Koby
D
,
Lavigne
A
,
Ludman
B
.
et al
Brief intervention for prenatal alcohol use: a randomized trial.
Obstet Gynecol
2005
105
991-8
PubMed
CrossRef

PubMed
Chang
G
,
McNamara
TK
,
Orav
EJ
,
Wilkins-Haug
L
.
Brief intervention for prenatal alcohol use: the role of drinking goal selection.
J Subst Abuse Treat
2006
31
419-24
PubMed
CrossRef

PubMed
Floyd
RL
,
Sobell
M
,
Velasquez
MM
,
Ingersoll
K
,
Nettleman
M
,
Sobell
L
.
et al
Project CHOICES Efficacy Study Group
Preventing alcohol-exposed pregnancies: a randomized controlled trial.
Am J Prev Med
2007
32
1-10
PubMed
CrossRef

PubMed
Flynn
HA
,
Marcus
SM
,
Barry
KL
,
Blow
FC
.
Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
Alcohol Clin Exp Res
2003
27
81-7
PubMed
CrossRef

PubMed
Grant
TM
,
Ernst
CC
,
Streissguth
A
,
Stark
K
.
Preventing alcohol and drug exposed births in Washington state: intervention findings from three parent-child assistance program sites.
Am J Drug Alcohol Abuse
2005
31
471-90
PubMed
CrossRef

PubMed
Meberg
A
,
Halvorsen
B
,
Holter
B
,
Ek
IJ
,
Askeland
A
,
Gaaserud
W
.
et al
Moderate alcohol consumption—need for intervention programs in pregnancy?
Acta Obstet Gynecol Scand
1986
65
861-4
PubMed
CrossRef

PubMed
O'Connor
MJ
,
Whaley
SE
.
Brief intervention for alcohol use by pregnant women.
Am J Public Health
2007
97
252-8
PubMed
PubMed
Reynolds
KD
,
Coombs
DW
,
Lowe
JB
,
Peterson
PL
,
Gayoso
E
.
Evaluation of a self-help program to reduce alcohol consumption among pregnant women.
Int J Addict
1995
30
427-43
PubMed
PubMed
Centers for Disease Control and Prevention (CDC)
Motivational intervention to reduce alcohol-exposed pregnancies—Florida, Texas, and Virginia, 1997-2001.
MMWR Morb Mortal Wkly Rep
2003
52
441-4
PubMed
PubMed
Halmesmäki
E
.
Alcohol counselling of 85 pregnant problem drinkers: effect on drinking and fetal outcome.
Br J Obstet Gynaecol
1988
95
243-7
PubMed
PubMed
Waterson
EJ
,
Murray-Lyon
IM
.
Preventing alcohol related birth damage: a review.
Soc Sci Med
1990
30
349-64
PubMed
CrossRef

PubMed
Handmaker
NS
,
Miller
WR
,
Manicke
M
.
Findings of a pilot study of motivational interviewing with pregnant drinkers.
J Stud Alcohol
1999
60
285-7
PubMed
PubMed
Saitz
R
.
Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking.
Drug Alcohol Rev
2010
29
631-40
PubMed
CrossRef

PubMed
Miller
WR
,
Walters
ST
,
Bennett
ME
.
How effective is alcoholism treatment in the United States?
J Stud Alcohol
2001
62
211-20
PubMed
PubMed
Babor
TF
,
Steinberg
K
,
Anton
R
,
Del Boca
F
.
Talk is cheap: measuring drinking outcomes in clinical trials.
J Stud Alcohol
2000
61
55-63
PubMed
PubMed
Del Boca
FK
,
Noll
JA
.
Truth or consequences: the validity of self-report data in health services research on addictions.
Addiction
2000
95
Suppl 3
S347-60
PubMed
PubMed
McCambridge
J
,
Kypri
K
.
Can simply answering research questions change behaviour? Systematic review and meta analyses of brief alcohol intervention trials.
PLoS One
2011
6
23748
PubMed
CrossRef

Appendix Figure 1.

Analytic framework for screening, behavioral counseling, and referral in primary care to reduce alcohol misuse.

KQ = key question.

Appendix Figure 2.

Summary of evidence search and selection.

Figure.

Forest plots for alcohol consumption, heavy drinking, and achieving recommended drinking limits for groups receiving behavioral counseling interventions compared with control groups.

Table 1.

Definitions of the Spectrum of Alcohol Misuse