1. www.aodhealth.org1 Journal Club Alcohol, Other Drugs, and Health: Current Evidence November-December 2012

2. Featured Article Behavioral Counseling after Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force Jonas DE, et al. Ann Intern Med. 2012;157(9):645–654.

3. www.aodhealth.org3 Study Objective To assess the benefits and harms of behavioral counseling interventions in people with alcohol use disorders.

4. www.aodhealth.org4 Study Design Systematic review and meta-analysis of 23 controlled trials of at least 6 months ’ duration that: –enrolled persons with alcohol misuse identified by screening in primary care settings, and –evaluated behavioral counseling interventions.

5. www.aodhealth.org5 Assessing an Overview Article (Systematic Reviews and Meta-Analyses) Are the results of the study valid? What are the results? Will the results help me in caring for my patients?

6. www.aodhealth.org6 Are the Results of the Study Valid? Did the overview address a focused clinical question? Were the criteria used to select articles for inclusion appropriate? Is it unlikely that important, relevant studies were missed? Was the validity of the included studies appraised? Were assessments of studies reproducible? Were the results similar from study to study?

7. www.aodhealth.org7 Did the overview address a focused clinical question? This overview addressed 7 well-defined clinical questions: 1.What is the direct evidence that screening for alcohol misuse followed by a behavioral counseling intervention, with or without referral, leads to reduced morbidity (e.g., alcohol-related morbidity or alcohol-related accidents and injuries), reduced mortality, or changes in other long-term (≥6 month) outcomes (e.g., health care utilization, sick days, costs, legal issues, or employment stability)? 2.How do specific screening modalities compare with one another for detecting alcohol misuse? 3.What adverse effects are associated with screening for alcohol misuse and screening-related assessment? (continued)

8. www.aodhealth.org8 Did the overview address a focused clinical question? (cont ’ d) 4.a) How do behavioral counseling interventions, with or without referral, compare with usual care for improving intermediate outcomes (e.g., change in mean number of drinks per drinking day or heavy drinking episodes) for people with alcohol misuse as identified by screening? b) How do specific behavioral counseling approaches, with or without referral, compare with one another for improving intermediate outcomes for people with alcohol misuse as identified by screening? 5.What adverse effects are associated with behavioral counseling interventions, with or without referral, for people with alcohol misuse as identified by screening? 6.How do behavioral counseling interventions, with or without referral, compare with one another and with usual care for reducing morbidity (e.g., alcohol-related morbidity or alcohol-related accidents and injuries), reducing mortality, or changing other long-term (≥6 month) outcomes (e.g., health care utilization, sick days, costs, legal issues, or employment stability) for people with alcohol misuse as identified by screening? 7.To what extent do health care system influences promote or hinder effective screening and interventions for alcohol misuse?

9. www.aodhealth.org9 Were the criteria used to select articles for inclusion appropriate? The authors 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 –evaluated whether a counseling intervention improved behavioral or health outcomes.

10. www.aodhealth.org10 Is it unlikely that important, relevant studies were missed?  The authors searched MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, and the International Pharmaceutical Abstracts from January 1, 1985 (the earliest publication date on the topic found in previous reviews) to January 2012.  Medical subject heading (MeSH) terms were used as search keywords.  The search was limited to English-language articles.

11. www.aodhealth.org11 Was the validity of the included studies appraised? Yes. –Internal validity was assessed using US Preventive Services Task Force criteria (ratings of good, fair, or poor) and University of York Centre for Reviews and Dissemination criteria, including assessment of a) randomization and allocation concealment, b) similarity of groups at baseline, c) masking, d) attrition, and e) whether intention-to-treat analysis was used. –Two independent reviewers assigned quality ratings for each study, with disagreements resolved by an experienced member of the research team.

12. www.aodhealth.org12 Were assessments of studies reproducible? Yes. –A minimum of 2 research team members participated in each step of the study assessments (search; review of articles marked for inclusion; data extraction, synthesis, and analysis; quality assessment; data analyses). –A link to the US Agency for Healthcare Research and Quality (AHRQ) technical report detailing methods and search strategies used is provided.

13. www.aodhealth.org13 Were the results similar from study to study? Study results were heterogeneous and based on a variety of counseling approaches.

14. www.aodhealth.org14 What Are the Results?  What are the overall results of the review?  How precise were the results?

15. www.aodhealth.org15 What are the overall results of the review? The best evidence was for 10- to 15-minute multi- contact interventions. Among adults receiving behavioral interventions, –consumption decreased by 3.6 drinks per week from baseline (95% CI, 2.4– 4.8 drinks per week) (10 trials, n=4332). –12% fewer adults reported heavy drinking episodes (risk difference, 0.12 [95% CI, 0.07– 0.16]) (7 trials, n=2737). –11% more adults reported drinking below recommended limits over 12 months compared with controls (risk difference, 0.11 [95% CI, 0.08– 0.13]) (9 trials, n=5973).

16. www.aodhealth.org16 What are the overall results of the review? (cont ’ d) There was not sufficient evidence to assess the effects of brief counseling on accidents, injuries, or alcohol-related liver problems. Young adults and college students reduced their consumption and had fewer heavy drinking episodes, (moderate strength of evidence). Little or no evidence of harms was found (e.g., increase in other substance use, increased smoking, anxiety, stigma, discrimination).

17. www.aodhealth.org17 How precise were the results? Change in alcohol consumption from baseline to 12 months Type of Counseling ReceivedDifference in Means (95% CI) p value Very brief counseling intervention (1 study) 2.700 (−5.212 to 10.612)0.50 Brief counseling intervention (4 studies) −3.660 (−6.349 to −0.970) 0.008 Brief multi-contact counseling intervention (5 studies) −4.407 (−6.084 to −2.730) 0.000 Extended multi-contact counseling intervention (6 studies) −2.546 (−4.767 to −0.325) 0.025 Total−2.546 (−4.767 to −0.325) 0.025 Heterogeneity statistics: Q=15.066; p=0.303; I 2 =13.714

18. www.aodhealth.org18 How precise were the results? Drinking within recommended limits at 12 months Type of Counseling ReceivedDifference in Means (95% CI) p value Very brief counseling intervention (2 studies) 0.080 (0.019 to 0.141)0.010 Brief counseling intervention (5 studies) 0.079 (0.039 to 0.120)0.000 Brief multi-contact counseling intervention (6 studies) 0.149 (0.109 to 0.188)0.000 Extended multi-contact counseling intervention (0 studies) —— Total0.109 (0.083 to 0.134)0.000 Heterogeneity statistics: Q=17.366; p=0.136; I 2 =30.900

19. www.aodhealth.org19 How precise were the results? No heavy drinking episodes at 12 months Type of Counseling ReceivedDifference in Means (95% CI) p value Very brief counseling intervention (0 studies) —— Brief counseling intervention (2 studies) 0.102 (−0.032 to 0.236)0.134 Brief multi-contact counseling intervention (4 studies) 0.106 (0.056 to 0.157)0.000 Extended multi-contact counseling intervention (2 studies) 0.191 (0.074 to 0.308)0.001 Total0.118 (0.074 to 0.162)0.000 Heterogeneity statistics: Q=8.457; p=0.294; I 2 =17.232

20. www.aodhealth.org20 Will the Results Help Me in Caring for My Patients? Can the results be applied to my patient care? Were all clinically important outcomes considered?

21. www.aodhealth.org21 Can the results be applied to my patient care? Potentially. –Some studies used clinical personnel in the process of providing clinical care, although some used ancillary research staff to provide the behavioral counseling interventions. The spectrum of alcohol misuse needs to be chosen appropriately (not excluding alcohol-dependent patients), and repeated versus single brief interventions should be provided.

22. www.aodhealth.org22 Were all clinically important outcomes considered? There was not sufficient evidence to assess the effects of brief counseling on accidents, injuries, or alcohol-related liver problems. The impact of brief alcohol interventions on the course of general medical problems (e.g. diabetes, hypertension) was not examined.