Screening and Brief Interventions for Prevention and Early Identification of Alcohol Use Disorders in Adults and Young People Commissioned by: NICE Centre for Public Health Excellence Produced by: ScHARR Public Health Collaborating Centre Authors: Rachel Jackson Maxine Johnson Fiona Campbell Josie Messina Louise Guillaume Petra Meier Elizabeth Goyder Jim Chilcott Nick Payne Correspondence to: Vivienne Walker School of Health and Related Research (ScHARR) University of Sheffield Regent Court 30 Regent Street Sheffield S1 4DA [email protected] 1 About the ScHARR Public Health Collaborating Centre The School of Health and Related Research (ScHARR), in the Faculty of Medicine, Dentistry and Health, University of Sheffield, is a multidisciplinary research-led academic department with established strengths in health technology assessment, health services research, public health, medical statistics, information science, health economics, operational research and mathematical modelling, and qualitative research methods. It has close links with the NHS locally and nationally and an extensive programme of undergraduate and postgraduate teaching, with Masters courses in public health, health services research, health economics and decision modelling. ScHARR is one of the two Public Health Collaborating Centres for the Centre for Public Health Excellence (CPHE) in the National Institute for Health and Clinical Excellence (NICE) established in May 2008. The Public Health Collaborating Centres work closely with colleagues in the Centre for Public Health Excellence to produce evidence reviews, economic appraisals, systematic reviews and other evidence based products to support the development of guidance by the public health advisory committees of NICE (the Public Health Interventions Advisory Committee (PHIAC) and Programme Development Groups). Contribution of Authors Rachel Jackson was the author, Maxine Johnson, Fiona Campbell, Josie Messina were additional reviewers. Louise Guillaume developed and undertook literature searches. Petra Meier provided topic expertise. Elizabeth Goyder, Jim Chilcott and Nick Payne were the senior leads. Acknowledgements This report was commissioned by the Centre for Public Health Excellence of behalf of the National Institute for Health and Clinical Excellence. The views expressed in the report are those of the authors and not necessarily those of the Centre for Public Health Excellence or the National Institute for Health and Clinical Excellence. The final report and any errors remain the responsibility of the University of Sheffield. Elizabeth Goyder and Jim Chilcott are guarantors. 2 CONTENTS 1 List of Abbreviations 4 2 Executive Summary 6 3 Background 32 4 Review Methods 4.1 Key principles of methods for identification of evidence 35 4.2 Review 4 36 4.3 Review 5 38 4.4 Review 6 42 4.5 Review 7 46 5 Review Findings 5.1. Review 4 49 5.2. Review 5 62 5.3. Review 6 127 5.4 Review 7 186 6 Discussion 228 7 Appendices 234 3 1. LIST OF ABBREVIATIONS A list of abbreviations used throughout this report is presented below. LIST OF ABBREVIATIONS AAF Alcohol-attributable fraction A&E Accident & Emergency AMI Adaptations of motivational interviewing AUDIT Alcohol Use Disorders Identification Test AuROC Area Under Receiver Operating Characteristic Curve BI Brief intervention CDT Carbohydrate-deficient transferrin CI Confidence Interval CTRL Control DSM Diagnostic and Statistical Manual of Mental Disorders EBI Extended brief intervention ED Emergency Department FME Forensic Medical Examiner G Gram GGT Gamma-glutamyltransferase GP General Practitioner Hr Hour HRQL Health Related Quality of Life ICD International Classification of Diseases ICER Incremental cost effectiveness ratios ITT Intention to Treat L Litre MAST Michigan Alcohol Screening Test MCV Mean corpuscular volume MI Motivational interviewing Ml Millilitre MNI Minimal intervention MVA Motor vehicle accident Min Minute NHS National Health Service NICE National Institute for Health and Clinical Excellence 4 NNT Number Needed to Treat NPV Negative predictive value NS Not Significant OR Odds Ratio PDG Programme Development Group PPV Positive predictive value QUOROM Quality Of Reporting Of Meta-analyses RCT Randomised Controlled Trial RR Relative Risk SASSI Substance Abuse Subtle Screening Inventory WHO World Health Organisation Wk Week U Unit Vs Versus 5 2. EXECUTIVE SUMMARY Background Alcohol misuse is associated with significant clinical and social consequences. The National Institute for Health and Clinical Excellence has been asked by the Department of Health to develop public health guidance to promote the prevention and early identification of alcohol- use disorders in adults and adolescents. Objectives To undertake an assessment of the clinical and cost-effectiveness of i) measures to detect alcohol misuse amongst adults and young people; ii) brief interventions to manage alcohol misuse among adults and young people; and iii) interventions to improve management of England’s alcohol market. Methods Systematic reviews of effectiveness evidence to address the above areas have been undertaken. Results This report includes the findings of the systematic reviews relating to patterns of alcohol consumption, screening, brief interventions, and barriers and facilitators to implementation of screening and brief interventions. Review 4: Patterns of alcohol consumption Information from recent UK reports of good quality was used to identify patterns of alcohol consumption in England, with data stratified by gender, age, socioeconomic status, ethnicity, and regional variations. The reports (NWPHO & Association of Public Observatories, 2007; NHS, The Information Centre, 2008) collated data from major national surveys (General Household Survey; Health Survey for England; Office for National Statistics Omnibus Survey; Department of Health Smoking, Drinking and Drugs in Adults / Young People), presenting figures relating to those groups that could be considered most ‘at-risk’ and least ‘at-risk’ of alcohol misuse. In addition, temporal trends are presented that compare such figures from the 1990s to 2006. Whilst useful, information from surveys needs to be interpreted with caution. Self-reported drinking is known to be under-estimated; total consumption from surveys accounts for approximately 50% of known alcohol sales in the UK. However, sales figures cannot provide 6 details of who drinks alcohol, how often, or in what quantity. Reports cited in this section were scrutinised to identify these data in order to inform those engaging in alcohol misuse prevention of the groups likely to be most or least ‘at-risk.’ However, it should be borne in mind that individuals from any group in society may present with signs of alcohol misuse or require advice to prevent harm. Data shows that among adults, 11% of men and 17% of women report abstaining from alcohol consumption. Among drinkers, men drink around double the volume of alcohol than that consumed by women. The highest mean consumption is among 45-64 year old men and 16-24 year old women of White ethnicity. Lowest average consumption is among older adults and in Pakistani and Bangladeshi communities. A trend was observed whereby more children are abstaining from alcohol over time but those that drink are consuming greater quantities of alcohol. Overall, average alcohol consumption has remained relatively stable over recent years. Figures from 2006 were recalculated to take into account the rising alcohol strength of some wines and beers, as well as larger measures used for wine. This particularly affected the figures associated with women’s drinking, as wine is the most commonly consumed alcoholic beverage, particularly in women aged 25 and over. Comparisons over time therefore need to consider both methods of calculation. There has been a slight decrease over time in reported consumption in the last week for both men and women, particularly in younger adult age groups. Among children, drinking in the last week was reported by similar numbers of boys and girls. Frequent drinking (at least 5 times in one week) was reported by almost double the number of men to women, and increases with age for both genders. Frequent drinkers were more likely to be high earners and live in the South East of England, and least likely to live in London or the North East. Children in school year 8 reporting consumption of 7 units of alcohol over 7 days were most likely to live in the East Midlands, and those in school year 10 in the North East. London was the least likely place of residence of any frequent child drinkers. Drinking at levels above recommended limits was more commonly reported in men, particularly in the 25-44 year age group. Women reported drinking hazardously at a younger age, from 16 years. White and mixed ethnicity groups were most likely to drink above recommended limits than other ethnic groups. 7 Heavy or ‘binge’ drinking was reported by more than twice the number of men than women. Men who binge were more likely to be aged 25-44 years, whilst a larger proportion of women reported bingeing from age 16 upwards. Bingeing was most likely in the North East or Yorkshire and Humberside and least likely in London. Indulging in heavy drinking was associated more with higher paid employees in full-time jobs, and least in less well paid and unemployed respondents. Alcoholic beverages most consumed by men and boys were beer, lager and cider. Wine was consumed by more women and middle-aged men, whilst in young people, and particularly