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Brief contact and written advice as effective as a longer talk for heavy drinking hospital patients
In Scotland handing heavy drinking medical inpatients a written guide to sensible drinking led to declines in consumption as great as more extended brief advice. The study seems to demonstrate the impact of being professionally identified as at risk due to drinking and the suggestion (even if conveyed by a minimal intervention) that you should consider cutting back.
Findings Over six months the featured study recruited 215 adult patients from among the 2307 admitted as inpatients to 16 wards in a general hospital. Steps were taken to exclude patients known to have serious drinking problems. Among the 819 not excluded for these or other reasons, screening tests identified 215 who had drunk excessively over the past week. In two-week blocks (to reduce ‘cross-contamination’ between patients), they were allocated to one of three alcohol advice options.
About a third (the control group) were left to the wards’ usual care. Another third met a mental health nurse who handed them a written guide to sensible drinking. The same nurse engaged the remaining third in a roughly 20-minute discussion intended to bolster confidence in their abilities to control drinking and to lead them to the point where they set their own change goals.
Six months later 172 of the 215 were reinterviewed. Typically men in their 40s, before being admitted half had drunk at least 35 UK units of alcohol in the past week. Those allocated to either intervention had on average cut their weekly drinking by 14 or 15 UK units. Compared to assessment and normal care, both interventions had led to a further reduction of 10 units a week, highly unlikely to have occurred by chance.
However, the interventions still left the patients drinking heavily. On average they still consumed perhaps about 30 units a week.
In context There are some concerns over the reliability of the findings (notably, many control group patients could not be reinterviewed), but none threaten the conclusion that the interventions led to equivalent drinking reductions relative to screening, research assessments and normal care only. 
Accepting this, a key question becomes why such a well structured brief intervention, delivered by an apparently highly skilled interventionist, to patients in the relatively conducive (the very ill were excluded) environment of an inpatient ward, had no greater effect than handing them an alcohol advice booklet.
Since the same interventionist handed over the booklet, one possibility is that this entailed some discussion which, though presumably shorter, drew on the same skills and content as the longer intervention. Another is that this mistakenly targeted confidence in ability to cut down when this was not the decisive obstacle, or perhaps muddied the water by asking patients to rehearse what for them were the benefits of drinking and by not giving clear advice.
But given other studies (detailed in the Appendix), perhaps most likely is that being identified as a risky drinker and professionally advised (as the offer of the booklet would probably have been interpreted) to consider cutting down, was sufficient to trigger such drinking reductions as there were going to be. The limits of what can be achieved by unsought intervention in situations where drinking is neither implicated in the patient’s condition nor a natural topic for clinicians to raise are typically quite low. Compared to assessment only, often no significant impact is observed, even after fully fledged brief interventions.
A recent analysis pooled results from studies of written advice on drinking accompanied by at most one face-to-face discussion with patients identified by screening. Several studies concerned hospital patients. The whole package of screening, assessment and intervention led to substantial drinking reductions, but there were major falls too after just screening and assessment, leaving a small (but still statistically significant) extra benefit from intervention. Its magnitude varied across studies, suggesting that even modest extra benefit was not guaranteed. Where this had been tested, sometimes very brief interventions were just as effective as longer ones.
Focusing on the UK, the picture is similar. Two studies of non-emergency hospital patients tested fully fledged brief interventions against a minimal intervention based on handing over an advice booklet with or without a warning about the patient’s drinking. In the first, relative to assessment only, both interventions led patients to cut drinking by on average 2–3 UK units a day. This study included some primary care patients. In the second, neither intervention significantly improved on assessment only; all the groups reduced their drinking to roughly the same degree. 
Beyond the UK, studies have also found more extended brief interventions offer no advantage over briefer ones.   The exception was an Australian study of psychiatric inpatients who screened positive as risky drinkers, which found greater reductions in drinking after a 45 minute intervention than after handing over a booklet. In the context of substantial falls in both groups, the difference was modest, and did not translate in to fewer hospital admissions over the five years after the interventions. Similarly at GP practices, more extended interventions lead to only slightly and statistically non-significant greater reductions in drinking.
A second key issue is whether any form of brief intervention, longer or shorter, is likely to reduce drinking in the non-emergency hospital setting. Compared to merely being assessed, one UK study found modest extra reductions, two found none,  and in another, the gains were questionable.
All these studies concerned the general run of patients. Two further UK studies concerned patients whose complaints meant that being talked to about drinking might have seemed a natural part of their medical care. Compared to assessment only, both found substantial drinking reductions after intervention. The most convincing study concerned young male outpatients with facial injuries after drinking. The second, of patients with high blood pressure, trialed a four-session intervention rather than the more usual one-off, compared it to perverse advice to carry on drinking, and the follow-up period was just eight weeks.
With the featured study, this work seems to show that in hospital patients, drinking reductions of the order of two or three UK units a day can be achieved by screening and brief intervention. However, none of the UK studies showed that longer and more sophisticated interventions were any more effective than being identified as a heavy drinker and given very brief advice and/or an advice booklet. On this issue of whether more is better, evidence from elsewhere is also unconvincing.
Practice implications Among hospital patients, screening for heavy drinking or drinking problems and offering very brief advice supplemented by written material to patients who screen positive seems a worthwhile preventive intervention, but there is no convincing case for more extended (if still brief) intervention. Gains might be greater in clinics or wards whose specialism makes enquiring about drinking integral to the core business of responding to the patient’s complaint, but even on general wards the proportion of heavy drinkers seems sufficient to make these fertile ground for screening and intervention. In the featured study, even after eliminating known problem drinkers, over a quarter of patients screened as excessive drinkers. Similarly, in the general wards of a London hospital, 28% of patients available for screening were identified as having a current substance misuse problem, for three quarters, involving alcohol.
The whole package of screening and intervention is likely at best to lead to modest reductions but enough, in a few studies which looked at this issue, to reduce the future load on health services. The rate of alcohol-related hospital admissions is an optional local indicator for English health authorities, relating to the national ambition to reduce that rate. Conceivably hospital based screening and brief intervention programmes could contribute to that objective as well as the national aim to curb alcohol-related violence and disorder. Such interventions could also contribute to national priorities to prevent or mitigate chronic diseases such as cancer, mental illness, heart disease, and diabetes, all related to drinking. 
These gains are potential rather than certain, but the cost of attempting to secure them is also low because the simplest, quickest and least costly interventions seem as effective as the more sophisticated and extensive. Given this, such programmes might be considered a worthwhile investment in public health terms and to provide an opportunity to identify individuals who need further treatment.
At the moment the policy focus in England and Scotland is more on alcohol screening in primary care and accident and emergency departments, but the Department of Health’s programme of improvement for alcohol misuse interventions saw general hospitals as one of the sites for such work, particularly clinics dealing with complaints often related to drinking. 
Though focused on other medical settings, practical guidance is available from a UK web site developed by leading researchers and an officially published US guide from the American College of Surgeons.

Appendix. Notes in support of bulletin entry: Brief contact and written advice as effective as a longer talk for heavy drinking hospital patients
Findings
Over six months the featured study recruited 215 adult patients from among the 2307 admitted as inpatients to 16 wards in a general hospital in Scotland. Though there was no upper limit on the amount they could drink before being excluded from the study, steps were taken to exclude patients known to have alcohol dependence problems. None of the wards dealt specifically with substance dependence and (along with other criteria) patients with a history of drug or alcohol dependence or mental illness, or who had been admitted primarily for treatment of alcohol-related complaints, were excluded from the study. From the 819 left, nearly all agreed to join the study. Among these 215 admitted to drinking heavily over the past week (operationalised as over 21 UK units for men and 14 for women) and were allocated to one of three alcohol advice options. Allocation was done in two-week blocks to reduce ‘cross-contamination’ between patients. 
All the 215 patients were asked about their drinking in the past week and they confidence they felt in their ability to turn down a drink in different situations. About a third were then allocated to the wards’ usual care procedures, probably amounting to little in the way of alcohol advice unless patients raised the topic themselves. Another third met a highly qualified mental health nurse experienced in counselling with what were described as well-developed interpersonal and communication skills who handed them a written guide to sensible drinking. The same nurse engaged the remaining third of patients in a roughly 20-minute discussion intended to bolster confidence in their abilities to control their drinking. 
For this intervention the nurse adopted the FRAMES model featuring an attempt to lead the patients themselves to acknowledge that they were drinking at a level which put them at risk and to consider cutting back. Patients were advised to keep a drink diary and to formulate alternative ways of gaining the benefits they perceived from drinking, and to initially avoid and then cope with the situations which led them to drink heavily. They were encouraged to set goals for their change in drinking and to learn from relapses rather than seeing these as a sign that they could not succeed. 
Six months later the researcher who had recruited them to the study reinterviewed 172 of the 215 participants. They tended to be men in their 40s half of whom were employed, who before being admitted to the hospital had typically (median) drunk 35 UK units (and on average across the baseline sample 44 units ) of alcohol in the past week, half on a single day and the rest on two other days. Six months later those allocated to either of the interventions had on average cut their weekly drinking by practically the same amount, 14 or 15 UK units. In contrast, patients assessed for the study but then left to the wards’ usual care had cut back by just 5 units. Compared to assessment and normal care, both interventions had led to a highly statistically significant further reduction of 10 units a week, composed of reductions in maximum daily consumption (small but also statistically significant) and in drinking across the remainder of the week. 
In Context 
About the study
The fact that even after eliminating known problem drinkers, over a quarter of patients screened as excessive drinkers seems to indicate that such wards are fertile ground for intervention. 
The interventions left the patients still on average drinking heavily two or three days a week but less heavily and on one fewer day than before. On average they still consumed perhaps about 30 units a week
Given the thought and expense that went in to it, the longer discussion would have been expected to prove clearly the most effective option. To what degree the same person interacted with patients in handing them the booklet is unclear. 
Of those not reinterviewed, 27 effectively refused. Loss to follow-up was about twice as great in the control group (22 of 76 patients). On the conventional assumption that they did not improve as much as the remainder, the effect would have been narrow the gap between intervention and control groups, suggesting that in reality the intervention benefit may have been even greater. However, this remains speculative. While overall those lost to follow-up were quite similar to those retained, there was no analysis of whether higher risk patients had been differentially lost from any of the groups. 
Unless volunteered by the interviewee, the researcher who interviewed the patients did not know to which intervention they had been allocated.
At baseline and at follow-up an assessment was made of the degree of confidence patients felt in their abilities to turn down a drink in various situations. Both active interventions led to increased confidence, particularly the discussion specifically designed to enhance confidence. Yet this (not quite statistically significant) extra boost in confidence had no effect on drinking itself, suggesting perhaps that confidence in ability to control drinking was not the main issue. The decisional balance exercise used as part of the intervention is possibly risky because it asks patients to itemise the good side of drinking as well as the bad.
Studies of alcohol brief interventions in hospitals
A review of controlled (mostly randomised) studies of alcohol brief interventions in hospitals excluding emergency departments found eight relevant studies. All of the trials excluded patients with serious medical or psychiatric disorders and five also excluded patients with a history of advice or treatment for drinking problems or severe alcohol dependence. Compared to the control group, just one of the studies recorded a significantly greater reduction in weekly drinking after the brief intervention. The verdict was that “Evidence for the effectiveness of opportunistic brief interventions in a general hospital setting for problem drinkers is still inconclusive.” 
Beyond this the evidence for non-targeted screening and intervention was entirely lacking because the single positive study concerned a setting and patients where asking about and discussing drinking would be expected.
What follows is a list of individual studies. This list excludes studies of patients seen in the emergency department before admission or who were never admitted.
Studies of emergency department patients confined to inpatient admissions
Patients screened for alcohol problems in a Swedish emergency surgical ward responded well to a simple brief intervention delivered by ward staff; outcomes were not further improved by professional counselling.
697 newly admitted inpatients were asked to participate in a study of alcohol and health. After being reassured that the results would not be entered into hospital records, 563 agreed and were screened by interview for alcohol problems using three standard scales (mast, cage and the Trauma Scale). Screening and the later brief intervention were conducted by alcohol treatment specialists or in a fifth of cases by ward medical staff. 
On at least one of the scales, 186 patients were assessed as problem drinkers and were allocated at random to one of two face-to-face interventions. Both were delivered while the patients remained on the ward. The first consisted of an immediate assessment of the patient’s drinking and of their readiness to change their drinking and brief feedback of the risks revealed by the assessment. With screening, on average it lasted under half an hour. The second duplicated the first but was followed by professional counselling lasting between one and 2½ hours to explore the patient’s concerns, compare their intake to safer drinking limits and population norms, and to offer further counselling and tests for impaired brain function. 
Six and twelve months later the assessment was repeated on nearly three-quarters of the 186 patients. In terms of baseline drinking (averaging 17 units a week), they did not significantly differ from the quarter who could not be re-assessed. About 30% were drinking on more days than before, twice as many as had reduced their drinking days. However, though drinking more often, as a whole the sample were drinking 13–16% less per day or week or as a daily maximum. Over 70% had reduced the number of times on which they had drunk sufficient on a single occasion to become intoxicated. Neither these outcomes nor readiness to change were improved by the added counselling or by having the brief feedback-only intervention delivered by alcohol specialists as opposed to ward staff. 
Outcomes were probably better than would be achieved in everyday practice. Ward staff conducted only just over a fifth of the assessments and brief interventions; whether they would have been able to handle the entire caseload and perform as well is unclear. Though they had received just a few hours training, the context of a research project would have allowed this to be more closely controlled and potentially of higher quality than everyday training. Possibly, too, the extra counselling did not provide a challenging benchmark against which to test the brief intervention, focusing as it did on medical concerns and raising the spectre of brain damage. Probably most patients were not in the process of changing their drinking behaviour and many will not even have been considering the possibility. For these patients a less confrontational approach aimed at enhancing motivation to change might have created added benefits. 
A serious gap in the evidence is the absence of a control group which received no intervention. Without this there remains the possibility that the improvements were not due to either of the interventions. Perhaps before entering hospital, the patients were at an atypical peak in their alcohol consumption and later simply resumed more normal drinking. Maybe, too, the focus on drinking in the screening procedure and in their agreeing to enter a study of alcohol and health provoked some salutary reflections. A further explanation is the human tendency to behave differently under observation. The prospect of being reassessed by the same study which had told them that their drinking was likely to harm them might have been an added incentive for patients to moderate their behaviour. To do otherwise would have risked appearing irresponsible. It is also conceivable that the pattern of results reflects what the patients were able or unable to hide. A high proportion of drinkers admitted to emergency wards are known to have been intoxicated and drinking heavily, facts which would have been hard to deny to a researcher on the same ward. At follow up, the extent of drinking to intoxication would have been easier to conceal. The outcome measures all related to alcohol consumption rather than problems, a limitation which might have obscured the benefits of the longer intervention.
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In a randomised controlled trial in a US regional trauma centre (deals with serious injuries), patients were screened using a blood alcohol concentration, gamma glutamyl transpeptidase level, and the short Michigan Alcoholism Screening Test (SMAST). At such centres half of all patients are admitted under the influence of alcohol. Patients with positive results and admitted for at least a day were randomised to a brief intervention or control group but led to believe they were entering a study concerned with their recovery from trauma. The half hour intervention was conducted by a specially trained psychologist on or near the discharge date. It adopted motivational interviewing techniques including feedback of results derived from the screening and research assessments and aimed to reduce the risk of alcohol-related injury. It was followed a month later by a personal, hand-written letter summarising the session. Re-injury was detected by a computerised search of emergency department and state-wide hospital discharge records, and 6- and 12-month interviews were conducted to assess alcohol use. 2524 patients were screened; 1153 screened positive (46%). 336 were randomised to the intervention group, and 396 to controls. Three-quarters were re-interviewed at six months and just over half at 12 months. At six months both groups had reduced their alcohol consumption but in the controls by 12 months this had risen to pre-intervention levels while in intervention subjects consumption continued to fall. The result was that at 12 months, the intervention group had decreased alcohol consumption by 21.8 drinks per week; in the control group, the decrease was 6.7 (p = 0.03). The reduction was apparent only in patients with mild to moderate alcohol problems (SMAST score 3 to 8); they drank 21.6 fewer drinks per week, compared to an increase of 2.3 drinks in controls (p < 0.01). Neither severely dependent patients benefited nor did those who screened negative for alcohol problems but were admitted to the study because blood tests indicated a high level of alcohol on admission. Though the experience of the injury seems to have prompted alcohol use reductions in employed and married/cohabiting patients, they gained no further benefit from the intervention, while unemployed single patients did benefit further. The added benefit of the intervention was attenuated in patients previously treated for alcohol problems among whom the benefit failed to reach statistical significance. These findings suggests a maximal impact in patients with a pattern of drinking problems rather than for whom the alcohol-related admission was a ‘once-of’, so long as these problems were not so severe that they exceeded the reach of a short intervention. Also benefiting most were patients who lacked the social obligations and supports which would prompt alcohol use reductions in response to injury and hospitalisation that the intervention could not improve on. Though the differences in injuries, arrests and traffic violations (overall and alcohol-related) did not achieve statistical significance, the reductions were consistently and substantially greater in the intervention patients, suggestive of a real protective effect from the intervention. Compared to controls, official records showed that at one year there was a 47% reduction in injuries requiring either emergency department or trauma centre admission, at three years a 48% reduction in injuries requiring hospital admission, a halving in the number of alcohol-related arrests, and a drop of 23% in drink-driving violations  The authors concluded that alcohol interventions are associated with a reduction in alcohol intake and a reduced risk of trauma recidivism. Given the prevalence of alcohol problems in trauma centres, screening, intervention, and counselling for alcohol problems should be routine. They claim that the intervention could be delivered after minimal training by trauma centre staff and that the main elements of the screening process (blood tests and screening interview) could easily be incorporated in routine admission procedures. In fact the intervention was made routine at the trauma centre featured in the study but the interventions were conducted by a specially hired and trained alcohol counsellor. 
Other studies of alcohol brief interventions in hospital
UK studies
731 admissions to male medical wards in a hospital in Edinburgh were screened for the study, a procedure which included questions about alcohol intake and related problems. 161 problem drinkers met the criteria for inclusion. All but five agreed to be studied. The person conducting the intervention was not responsible for medical care on the ward. Allocation was alternated by ward to either control group who received no further intervention or to one hour of counselling. Though not identified as motivational in nature, the session deployed some elements used in motivational interviewing including encouraging the patient to weigh up the drawbacks of their drinking and to make a commitment to changing it, and the interventionist was an alcohol specialist nurse known for her empathic style. A year later across both this group and the normal care control group, average past-week alcohol consumption was half the pre-intervention level, with negligible differences between the groups. Though the number of individuals who halved their consumption was higher in the intervention group (64% v. 48%), this narrowly missed reaching the conventional criterion of statistical significance. Though counselling may not have further reduced consumption, it did create significantly greater reductions in alcohol-related problems (medical, social and dependence). However, this may just have been because despite randomisation the intervention group started at a higher level and fell back to the same level as the control group. Unfortunately the scale used to measure problems does not appear to have been a validated scale with proven reliability. There were also greater improvements in a composite characterisation of the proportion “definitely improved”. Readmissions and (more so) lengthy readmissions (four people versus 11 in the control group) during the year were lower in the counselled group but the report did not specify whether the differences were statistically significant. Given the small numbers, it is unlikely that they were. The patients in this study were heavier drinkers (averaging 70 UK units) than in the featured study.
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In Cardiff in 1997–1998 219 young men with facial injuries were referred for treatment a few days later at an outpatient specialist jaw and face clinic. Most had been involved in a fight. Research assessment at the clinic identified 151 who had consumed at least 8 units of alcohol before the injury, met other study inclusion criteria, and consented to participate. They were randomised to normal care or to a brief alcohol intervention lasting up to 20 minutes and based on motivational interviewing principles. It was conducted immediately at the clinic by two senior general nurses trained in the technique. Nearly all scored above the AUDIT level for hazardous or harmful drinking but were not highly dependent on alcohol. Follow-up data was collected on about 90% at three months and 80% at 12 months. In the control group alcohol consumption over the past three months or in a typical week had barely changed but in comparison there had been a significantly greater reduction in the intervention group. Before intervention in a typical week the patients drank about 32 UK units. A year later this was unchanged in the control group but had fallen to about 22 units a week in the intervention group. At 12 months half the control group were still drinking above recommended limits (21 units a week) but just 27% of the intervention group (down from 60% at baseline), a statistically significantly difference. Similarly though virtually all scored above the AUDIT cut off point at baseline, as 12 months this had dropped to 58% in the intervention group but to just 81% in the controls. Change was greatest in this who had been drinking most at baseline and was most evident at the later follow up. 
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The one positive study in the Emmen review concerned patients with high blood pressure. Abstract: “The relation between alcohol consumption and blood pressure is well recognised, and advice to reduce alcohol plays an important part in the management of hypertensive patients. We have evaluated the effectiveness of this advice in a randomised, controlled, single-blind clinical study. After a 2-week run-in period, hypertensive men regularly consuming more than 20 units/wk (1 unit=10gm) of alcohol were randomly assigned either to the "advice" or control group and were seen at 2-week intervals over an 8-week study period. The outcome measures were: reported alcohol consumption (1-week retrospective diary), markers of alcohol consumption (serum y-glutamyl transpeptidase, aspartate amlnotransferase, uric acid, mean corpuscular volume), and blood pressure (sitting and standing). Over 18 months, 67 men who drank more than 20 units/wk of alcohol were seen. Twenty-six either were excluded, refused to participate, or dropped out due to non-attendance. Forty-one patients completed the study. After intervention, reported alcohol consumption fell from 60 units/wk to around 30 units/wk in the advice group, whereas it remained between 50 and 60 units/wk in the control group (analysis of variance [ANOVAJ F=7.1, p<0.05). This was accompanied by falls in y-glutamyl transpeptidase (20.9%) and aspartate aminotransferase (18.1%), but no significant changes were seen in the control group. Standing diastolic blood pressure fell significantly in the advice group (from 101.5 mm Hg to 96.3 mm Hg) compared with the control group (ANOVA F=4.8,p<0.05). The results suggest that advice to reduce alcohol consumption is a useful form of treatment for hypertensive patients who drink excessively.”
Further comments: conducted in Birmingham in a clinic dealing with high blood pressure, published 1992. The article comments that “In clinical practice, these patients would routinely be asked to reduce alcohol” yet the control group “were told that they could continue with their usual alcohol consumption.” In contrast, “Patients in the advice group were told to reduce their alcohol consumption as much as possible [and] told that reducing alcohol may well help in controlling their blood pressure ... The advice was reinforced at subsequent visits and encouragement given to maintain any progress made.” In other words, the study was a test of targeted advice more or less following normal clinical practice compared with deliberately perverse clinical practice. Usually the comparison is between structured advice intended to improve on normal practice versus normal practice. The doctor who gave this advice also asked the questions which yielded the past-week drinking amounts. This and the short-term nature of the study (just 10 weeks in total) cast some doubt on the validity ands persistence of the findings. Blood pressure was taken by an assistant blinded to the patient’s allocation. The significantly greater fall in y-glutamyl transpeptidase was from a higher level in the advice group down to the same level as the control group. Only one of four blood pressure measures was reduced significantly more in the advice group. 
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The British arm of the WHO study (see below) foundered on the reluctance of GPs and patients to get involved. Perhaps because of the research requirements, only three health centres participated, forcing the study to seek further subjects wards in the medical wards of two general hospitals in Cardiff where implementation was easier. 961 hospital patients were screened and 115 (a number set in advance) were recruited to the study, all men. Suspected dependent drinkers were excluded. Nearly half the excessive drinkers identified by the researchers refused to take part in the study. Over two-thirds of the entirely male follow-up sample re-assessed about eight months later had been recruited in the hospitals, comprising 76 of the 115 patients. The results probably largely reflect their progress, but the results were not disaggregated so it is impossible to be sure. Even if they had been, the loss to follow-up of a third of the patients would cast doubt on the findings. The sole statistically significant finding was a greater reduction in average daily alcohol intake during a typical month in the advice groups relative to the controls. Judging by the differences in average amounts drunk, this greater reduction in drinking was most apparent in the group given the shorter of the two interventions, five minutes of advice that their drinking might place them at risk. Before intervention the patients were drinking on average 8.5 centilitres of alcohol daily. The extra reduction relative to controls amounted to 2.54 centilitres of alcohol, the equivalent of two and half UK units or 20g alcohol. Overall the reduction amounted to 3.2 centilitres. Supplementing brief advice (five minutes during which patients were told their drinking might place them at risk) with 15 minutes of counselling did not improve outcomes. Both groups were given written advice and the longer intervention was based on a self-help manual also given to the patient. On their own neither of the components of amount drunk (amount drunk on a drinking day and the number of these days) fell significantly more after advice, nor did related problems or level of dependence. In both settings some patients did not see their drinking as excessive and in practice nurses had to negotiate the intervention with the patient rather than simply delivering it.
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A UK study included inpatients admitted to four wards in a large Scottish general hospital. 1221 were admitted during the study, 998 interviewed, 225 admitted drinking more than the UK recommendations of the time (21 units men, 14 women), 153 had not previously been treated for alcohol problems and drank regularly rather than sporadically, and 150 agreed to join the study. Typically the patients drank 33 UK units a week and (to judge from the problems they reported) perhaps a third were dependent. In four-weekly cycles the wards implemented one of three interventions or none at all (the control condition). For one intervention the researcher simply handed patients an official guide to sensible drinking, for another the same researcher advised the patient for 10–15 minutes using feedback from the assessment, for the third she did both. A year later another researcher unaware of the allocation re-assessed two-thirds of the patients, data from whom was included in the analyses. All the groups including the assessment-only control group (in that case the reduction was about 15 units) had substantially curbed their drinking. Only the average reduction in the patients given advice plus booklet exceed that in the control group, but only by six units and the difference was not statistically significant. Neither were the differences in reductions in alcohol-related problems or levels of chemicals in the blood indicative of heavy drinking. 
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428 patients admitted to nine medical and orthopaedic wards of a general hospital in York were screened by ward staff and a researcher and identified as drinking at unsafe levels. According to a monthly timetable, patients were allocated to be taken by ward nurses to view an alcohol education audio-visual presentation and receive the booklet on which it was based, or to the ward’s normal care only (except that in all cases ward consultants were informed about their patient’s excessive drinking). On average they drank over 40 UK units a week. 361 of the 411 surviving patients were re-interviewed a year later and 333 provided data. At follow-up, about a third of the patients shown the presentation reported a  reduction in their alcohol-related health problems, significantly more than in the control group (22%). However, there were no significant extra reductions in three other problem areas nor in consumption levels, which on average had fallen modestly by just over a unit a day (this data was available from just 214 patients), leaving three quarters of both groups still drinking to unsafe levels as initially assessed by the study. 42 of the control patients recalled being advised about their drinking I the course of normal care while in hospital. They tended to be the heavier and more problematic drinkers. They had made greater improvements on average in their problem scores and proportion drinking to unsafe levels than the patients shown the presentation but, not significantly greater. Regarding the potential impact of the assessment interview, the researchers comment that “Certainly, those patients who felt affected by the interview reduced their mean consumption ... to significantly lower levels than those who felt unaffected by the interview”.
Non-UK studies
In New Zealand a study similar to the Chick study in Edinburgh also found that a year later reductions in consumption were no greater in hospital patients referred for help with their alcohol problems as opposed to those simply assessed. Screening was carried out by two specially trained nurses. 62% of those offered counselling accepted and within a day received counselling at the hospital from an alcohol specialist. However, the referral option did result in benefits in at least short-term abstinence, in alcohol-related problems and in the patients’ quality of life. Hospital records indicated that 13% of the referral group patients and 21% of controls would be re-admitted within two years but this difference was not statistically significant.
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In 1996 an Australian study set in hospital wards reported a statistically significant difference in alcohol consumption after counselling compared to merely assessing the patient; about six months later a typical subject drank 13 units less a week. Patients were not severely dependent, the number who refused to join or were lost to the study was high (373 were screened as eligible heavy drinkers and 123 were able to be followed up), and whether the added value of counselling would have persisted to a 12-month follow-up is unknown. Despite these limitations, this was the first study to have demonstrated reduced consumption from a brief intervention relative to assessment alone. In the whole sample there was a tendency for reductions to be greater after motivational than skills-based counselling which was statistically significant among patients assessed as not yet ready to change their drinking (the majority) – a clue that the motivational style might be best suited to this environment.
Both interventions were carried out by three counsellors of whom two were specialists in alcohol problems or motivational interviewing. Similar results may not be achieved by less skilled and experienced staff. The possibility that the counsellors were more skilled at, or enthusiastic about, motivational than skills-based counselling cannot be excluded.
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In 1988 New York State established a pilot early intervention programme to identify and respond to general hospital patients with or at risk of alcohol dependence. Special intervention teams screen all patients for actual or potential alcohol-related harm suggested by patient notes or by cage. Interviews with those screening positive were used to exclude ‘false hits’ and to assess the remainder as:
– ‘dependent’ – dependent on alcohol and/or suffering serious alcohol-related problems; they were encouraged to accept referral to treatment and followed up;
– ‘problem drinkers’ – those not ‘dependent’ but still experiencing alcohol-related problems or drinking over about three UK units a day. They received an information-based risk-reduction intervention but no referral or follow up.
Four years into the programme state authorities selected four of the nine pilot hospitals for evaluation and three similar non-programme hospitals as control sites. At evaluation sites positive screen patients were asked to enter the study, at control sites a random selection of all patients. Of those who accepted 377 evaluation patients and 296 controls were interviewed and met the research criteria for past or current alcohol problems. Six months later 75% were successfully re-contacted to assess their progress. To compare dependent drinkers with controls statistical methods were used to recalculate outcomes as if the two groups had been equally dependent on alcohol. Dependent drinkers were successfully encouraged to seek help and after six months admitted to 60% fewer heavy drinking days (effectively a measure of binge drinking) compared to just 24% in controls. After adjustments the difference amounted to one less heavy drinking day a month among those referred for help. Quantities drunk and associated problems were unaffected and there was no evidence that this option had a greater impact than the risk-reduction intervention. This may have been because relatively few patients opted for formal treatment. The risk-reduction intervention was correctly targeted at just 13% of patients who screened positive at the intervention sites, for whom it was ineffective. But among 18 patients to whom it was misapplied (because they were dependent enough to have been referred for treatment), it did cut the amount and how often they drank as well as problems. For example, compared to controls this dependent group drank on 15% fewer days in the six months following the intervention, a serendipitous finding which must be considered highly tentative.
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WHO’s trial of brief alcohol interventions in primary care in eight nations was conducted at a variety of settings including general hospital wards and emergency departments. The relative impacts of the interventions did not differ across the different sites. After an assessment of alcohol use and related problems, patients whose consumption placed them risk of alcohol problems were given either no further intervention, five minutes of feedback and advice, or 15 minutes of counselling. Some sites supplemented the initial counselling with the offer of follow-up sessions but (possibly because so few patients returned to receive it) this had no extra impact. All the groups including those who had merely been assessed had reduced their drinking at the nine-month follow-up, but among the men the reductions were greater in the intervention groups, and fewer men in these groups were drinking at hazardous levels. However, the extra impacts of the interventions were modest and no greater from the longer of the two. There were no significant extra impacts among women, just 1 in 10 more men cut their alcohol consumption compared to screening, and the average extra reduction in male drinking amounted to about a unit a day, not enough in this study to significantly curtail alcohol-related problems.
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At a Texas hospital 326 Mexican-American patients screened as heavy drinkers and were randomised into four groups. In the first, the doctor conducted a 10–15 minute confrontation and discussion. The second was a psycho-educational intervention over six 90-minute sessions which covered alcohol-related problems and possible solutions, followed by a group discussion. The third group received both interventions, the fourth none. Family members were encouraged to become involved in the interventions which stressed abstinence and AA involvement. Just over half the subjects completed baseline and follow-up interviews at 12 and 18 months. 
All four groups improved in drinking and psychosocial problems, with no significant differences between them. The authors attributed the negative findings to statistical limitations and to the possibility that extended assessments and the transparency of the study’s purpose boosted outcomes, even when there was no intervention. Other possible explanations are that Mexican-Americans and people of European descent respond differently, that abstinence may have been an unsuitable objective, and that the interventions were simply ineffective. Despite their popularity in the USA, confrontational interventions have not been found to be effective.
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An Australian study set out to evaluate the 6-month outcomes of a brief intervention to reduce alcohol consumption by psychiatric inpatients in the general hospital setting following resolution of psychiatric morbidity. Patients from the psychiatric wards of three general hospitals were screened using the audit. Of 144 people approached who matched the study criteria, 120 (83%) aged 18–64 years (mean 31.7) were recruited. Participants were randomised to either a brief motivational interview or an information package to reduce alcohol consumption. Alcohol consumption was assessed as total weekly consumption and categorised on Australian National Health and Medical Research Council (NH&MRC) criteria as safe, hazardous or harmful. 62 motivational interviews were delivered and 58 information packages. 
At the 6-month follow-up 83 (69%) participants were reassessed. Both groups had significantly reduced their past-week alcohol consumption compared to the week before admission. However, the motivation group had a significantly greater reduction in weekly consumption than the information group after controlling for age, sex, SCL-90-R GSI and alcohol dependence (and baseline alcohol consumption). At baseline the median for the motivation group and information group were 45 UK units and 41. Six months later the respective medians were 8.5 and 12.5. A significantly greater proportion of the motivation group compared to the information group also improved in their classification on Australian National Health and Medical Research Council criteria. The authors concluded that brief interventions, especially motivational interviews, are effective in reducing alcohol use in psychiatric inpatients with disorders across the mid-range of GSI severity scores.
Severely dependent and very seriously mentally ill patients were excluded from the study. Experienced clinical research staff undertook the 45-minute intervention. Both groups reduced their drinking substantially, probably reflecting the resolution of the crisis that led to their admission, a form of regression to the mean. Part (but not all – baseline consumption was controlled for in one of the analyses) of the advantage of the motivational interview derived from the fact that subjects in this group had further room to regress, having started with higher drinking levels. When room for improvement was equalised somewhat by excluding patients who started with safe levels of drinking (and who did not worsen – very few did) the greater gains in transition to safer drinking levels in the motivation group were no longer statistically significant. A gap in the evidence is the absence of a control group which received no intervention. Without this there remains the possibility that the bulk of the improvements (at least to the level of those seen in the information group) were not due to either of the interventions. 
Five years later hospital records showed that the intervention groups had benefited equally relative to the control group in terms of apparently reduced need for alcohol-related, other general hospital or mental health admissions.
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In a recent US study patients were recruited from the inpatient medical service of an urban teaching hospital. All subjects were at least 18 years old and did not have a significant history of dementia. 
All patients were screened for problem drinking, which was defined by drinking more than 14 US drinks per week or 5 or more drinks per occasion among men and more than 11 drinks per week or 4 or more drinks per occasion among women and persons 66 years and older. 
Participants found to have problem drinking were randomised to a group receiving usual care and a group that received a 30-minute session of brief motivational counselling regarding alcohol consumption. Counselling was provided by trained psychology doctoral students and included a plan for change. 
The main study outcome was self-report of receiving assistance to reduce alcohol consumption within 3 months of hospital discharge. The other main outcome was the mean number of drinks per day in the previous 30 days at 12 months after discharge. Other outcomes included the number of heavy drinking episodes, 30-day abstinence from alcohol, a measure of readiness to change, quality-of-life measures, and days of repeat hospitalisation. Results were adjusted for baseline risk factors for addiction.
5813 patients were screened for problem drinking, and 17% qualified for study participation. 29% of subjects were women, and the mean age was 44 years old. More than three quarters of the entire study cohort had alcohol dependence. 
90% of subjects completed at least one follow-up visit. At 12 months, similar numbers of participants in the intervention and control groups recollected receiving the brief intervention (37% and 28%, respectively), suggesting that the memory of the intervention was poor. 
Rates of seeking assistance to curtail alcohol use were similar between the intervention and control groups (49% and 44%, respectively). The brief intervention was also ineffective when researchers limited their analysis to patients with higher levels of alcohol consumption. 
Alcohol use decreased in both treatment groups at 12 months, but the degree of alcohol reduction was similar in the brief intervention and control groups (-2.6 and -1.8 drinks per day, respectively). 
Secondary outcomes were also similar between the brief intervention and control groups, with the exception that the control group actually had a superior outcome in the number of days abstinent from alcohol in the prior 30 days. 
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Rather different from the other studies is a study of men aged 46–53 whom biological tests suggested were moderate to heavy drinkers. Instead of being identified while attending hospital for another reason, they had specifically been invited to hospital for health screening. Still the study shows the potential for long-term but brief contacts to reduce the demand on the health service and to create social cost savings. Men living in Malmö in Sweden born in 1926–1933 were invited for health screening at a local hospital. Three-quarters attended. Two tests identified the top tenth with consistently elevated CGT levels indicative of moderate to heavy drinking. Half those born in all but the first year of the study (261 men) were invited to participate in the intervention. On interview three-quarters confirmed moderate to heavy drinking and as many as 30% were considered dependent on the criteria of withdrawal symptoms. The intervention began with this assessment at the outpatient clinic and continued with monthly nurse contacts to reinforce counselling and discussion consultations with the doctor every three months, providing long-term frequent contact with the same counselling team. The target was to contain CGT levels to normal by moderating consumption through lifestyle change and change in drinking habits, a form of bio-feedback strategy. The men were not treated as ill but given full responsibility for making the changes with the encouragement and support of the medical personnel. When CGT levels stabilised therapeutic contacts were cut down. The control group were generally told by letter that they had impaired liver function, advised to restrict their drinking and informed that they would be re-tested in two years. Those (56 out of 268) who responded by getting further medical help which included a stress on drinking were excluded from the control group leaving 212 men. The controls’ CGT levels were tested at two, four and six years. The average CGT level in intervention group up to two and four years was compared with measures taken at two or four years in the controls. The differences between the groups were not statistically significant. However, in the five years after screening hospital records showed that the control group had been hospitalised for over twice as many days and for known physical alcohol-related conditions for 4–5 times as many. Days per year increased far more steeply in the control group over the four years since screening until by year four there was a statistically significant difference of 22 days on average per man. Differences were pronounced for mental illness days and for accidents and injuries, the ratio in both cases being three. There were also twice as many deaths (ten) in the control group and of these four versus two in the intervention group were probably alcohol-related. How far the differences were due to an impact on drinking and how far to regular clinical contact improving general health is unclear. 
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Also in Sweden from a population of 2,114 outpatients attending Karlstad hospital emergency, orthopaedic, medical or surgical departments, and a district health centre, 78 were selected who had either an excessive consumption of alcohol (200gm or 24 UK units a week men, 150gm women) according to questionnaires or a raised gamma glutamyltransferase (GGT) value due to alcohol. On average they drank 20 UK units a week. Patients were excluded from the study of had previously undergone treatment for problem drinking, or had serious alcohol dependence. The 78 patients were randomly allocated to an intervention (n = 36) or to a control group (n = 42) who received no further assessments or advice about drinking. Those in the intervention group were followed up by a nurse once a month and by a doctor every third month for a total of 12 months and were advised to cut back their drinking with reference to the results of monthly laboratory tests measuring blood levels of chemicals indicative of heavy drinking and potential resultant harm. The control group’s blood was also tested a year later but their alcohol consumption was not measured. Consumption of alcohol (down from 164gm a week to on average 117gm), GGT and triglyceride levels, and sickness allowance days were decreased in the intervention group compared to the time before intervention. In contrast, the number of sickness allowance days in the control group increased (and more patients were removed from this measure altogether due to receiving a disability pension) and the difference between the groups in the two years after the study year was statistically significant. How far this was due to an impact on drinking and how far to regular clinical contact improving general health is unclear. Only 23 of the 42 control patients gave a follow-up blood sample. Though CGT levels had fallen more in the intervention group, this was from a higher starting level and the difference was not statistically significant. There was also a tendency towards a positive effect of intervention on the number of medical consultations following intervention.
Written advice as a brief intervention
A meta-analysis of the effectiveness of written advice for alcohol problems found decreased drinking after the interventions but a smaller difference between patients given this advice and assessment-only control groups, suggesting that the advice does have an extra impact but also that merely being enrolled in the study and assessed was also influential. Specifically in relation to people identified through screening, two studies demonstrated that minimal advice (lasting for example five minutes) supplemented by written materials was more effective than assessment only at reducing drinking and as effective as more extended advice. In one of these (which had long-lasting effects) the patients had been selected as showing signs of liver disease and the relation between this and alcohol had been explained to them. The other was the WHO study outlined above. One imperfectly implemented study found no extra impact of written advice compared to assessment-only (the same was true of advice from a doctor) while others found written advice supplemented varying periods of face-to-face advice preferable to assessment only. When results from these studies were pooled there had been a large and significant fall in drinking (effect size 0.65) following interventions featuring written materials and at most one brief advice session, but the effect was much smaller (the effect size was cut by two thirds to 0.21) in comparison with the falls there had also been after assessment only, and slightly and non-significantly smaller than the falls after more extensive advice. The magnitude of the impacts varied significantly across studies. The reviewers’ verdict was that benefits were unclear and probably modest but perhaps enough to warrant such interventions given their low cost. 
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A later study not included in the review above was conducted in a US hospital trauma (acute injury unit). 40 patients who screened as hazardous drinkers or with alcohol in their blood were randomly assigned to assessment only (including AUDIT) or to be handed a booklet on which relevant results from this assessment were recorded. The standard content in the booklet gave national drinking norms and encouraged patients to weigh the pros and cons of their drinking, record their drinking, and make plans to change it. The content was explained to the patient for up to five minutes. Five months later 30 patients were re-assessed. Though both groups had substantially improved, the booklet had not led to any significant extra reduction in drinking or drink-related problems. Five of seven assessment-only patients (71%) and eight of 10 given the booklet condition (80%) went from risky to low-risk levels. The biggest difference between the groups was that 6 of the 15 patients given the booklet had sought further help or information compared to just two in the assessment-only group. The conclusion was that the (in many cases, potentially alcohol-related) hospital admission and the assessment process had led to reductions in drinking which merely handing over a booklet did not improve on. 
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A Cochrane review synthesising evidence on primary care (mainly GP practices) brief interventions for risky drinking concluded that more extended interventions led to only slightly and statistically non-significant greater reductions in drinking.
Practice Implications
A US guide to screening and brief interventions in emergency departments may be of use as a guide to similar interventions in other hospital settings.
Of 2183 patients available for screening in the general wards of a London hospital, 28% were identified as having a current substance misuse problem, for three quarters involving alcohol.
The English Department of Health’s programme of improvement for alcohol misuse interventions saw general hospitals as one of the sites for expansion in alcohol screening and brief intervention, particularly clinics dealing with complaints often related to drinking. The programme fulfils a commitment given in 2004 in the national alcohol strategy. That strategy favoured targeted screening of patients whose complaints suggest possible drinking problems rather than universal screening. The studies piloting this work are however not taking place in hospital wards but in accident and emergency departments and GP practices. Among the researchers will be the Newcastle team which conducted the WHO trials in England. They have developed a brief intervention protocol called How much is too much? based on the brief advice intervention tested in the WHO trials. This advises screening adults using AUDIT or shorter screens such as FAST and suggests “You might consider targeting certain consultations, e.g. new patient registrations, well-person clinics or diabetes and hypertension clinics.” Simple advice or extended brief interventions are advised for hazardous and harmful drinkers respectively. These consist of assessment feedback compared to national norms, advice on what to cut down to and how, and on the benefits of doing so, plus in the extended version motivational style probing of the patient’s desire for and confidence in their ability to cut down, a decisional balance exercise and more detailed planning.
This protocol is recommended in English NHS guidelines for commissioning alcohol screening and brief intervention from GPs as an enhanced service. Screening with very brief tests is recommended to be followed by the full AUDIT for patients who screen positive. 
A discussion paper on a Scottish alcohol strategy released in 2008 proposes to “expand screening to enable early identification of people who are misusing alcohol but may be unaware they are doing so, and delivery of brief interventions to help prevent them from developing problems”. However, general medical wards do not appear as a priority. Instead the focus is on primary care and “acute settings.” As in England, universal screening is not recommended. Instead it suggests that health services “opportunistically screen people who may be at risk” according to the model recommended by a Scottish medical and research network. For primary care this recommends “judicious” use of screening tests on suspicion of drinking problems and routinely as part of the medical history documented for new patients. Any ensuing intervention should it suggests relate to the patient’s presenting problem wherever possible, reflecting concern not to pre-empt the agenda and to have screening and intervention arise naturally within a patient-centred consultation. Apart from primary care, screening and referral is considered appropriate for accident and emergency departments and screening and brief intervention for antenatal clinics, but no mention is made of other hospital settings. 
An optional local indicator for English health authorities is the “Rate of hospital admissions per 100,000 for alcohol related harm”, relating to the national ambition to reduce that rate. Conceivably hospital based screening and brief intervention programmes could contribute to that objective as well as the national aim to curb alcohol-related violence and disorder. Such interventions could also contribute to national priorities to prevent or mitigate chronic diseases such as cancer, mental illness, heart disease, and diabetes, all related to drinking.