The Theoretical Basis for drinkbreak - part 2 of 2

Welcome back.  In this blog we continue to provide background information about the scientific and clinical basis of drinkbreak.  The blog is aimed at practitioners who want to assure themselves that intervention has a solid basis and firm footing in evidence ad experience.  

Screening and Brief Intervention (SBI) is an intervention that has been developed for the large group of hazardous and harmful drinkers who would not otherwise access treatment.  This group carries the burden of most alcohol-related harm, therefore interventions directed toward this group may be able to significantly reduce the harms associated with excessive consumption.  Brief interventions are recommended by NICE as they have the potential to help reduce the aggregate level of alcohol consumed and thus lower the risk of alcohol-related harms for the entire population.

The elements of a brief intervention are derived from the basic principles of motivational interviewing and are summarized in the FRAMES model:

• Feedback on the risk for alcohol problems.

• Responsibility: where the individual with alcohol misuse is responsible for change.

• Advice: about reduction or explicit direction to change.

• Menu: providing a variety of strategies for change.

• Empathy: a warm, reflective, empathic and understanding approach.

• Self-efficacy of the misusing person in making a change.

The tools and means to deliver SBI vary between settings, many of which are opportunistic such as primary care.  The most popular screening tool is the 10-item multiple choice Alcohol Use Identification Test (the AUDIT)  A briefer version, the AUDIT-C, includes only the three consumption questions and has been shown to effectively identify hazardous drinkers.

The feedback element of a brief intervention may be provided simply as information that informs the individual about their level of risk, or as a more complex and personalised encounter with a trained healthcare professional or alcohol counselor. Similarly, the provision of options about strategies for change may be a printed list or a personal interview. Clearly these are very different modalities, and the full FRAMES approach assumes that the feedback is given by someone with the appropriate personal qualities (warmth and empathy) and therapeutic training (such as in motivational interviewing).

The evidence for the efficacy of SBIs is strong and there have been numerous studies and meta-analyses demonstrating positive outcomes for the approach.  A Cochrane review included over 7,000 participants in 24 trials in general practice and five trials in emergency settings. The reviewers conclusion was that after one year or more those people who had received a brief intervention drank less alcohol than the control groups (average difference, 38 grams a week).

However it has not all been plain sailing.

A major programe - The Screening and Intervention Programme for Sensible drinking (SIPS) - consisted of cluster randomized controlled trials in three different UK settings: primary care, emergency departments and probation services.  In primary care, brief interventions had no benefit over a simple information leaflet. The study in emergency departments, a large, multicenter study, found that it was difficult to implement brief interventions in emergency-department settings for a variety of practical reasons; however, when these difficulties were overcome, they also found no benefits for a brief intervention. Similarly, structured brief advice or lifestyle counseling had no advantages over an information leaflet delivered to offenders by probation officers. 

In conclusion there is strong evidence for small and consistent benefits of SBIs; but when evaluated in some naturalistic clinical or social settings the same results have not been found.  Determining the reasons for these discrepancies is an active area of ongoing research and no firm conclusions have yet been reached.  Suggested explanations include differences in staff training between research and non-research settings; intervention integrity and adherence; selection of subjects and the differential impact of the trial procedures themselves, particularly reactivity associated with the burden of the assessments.

Bringing this research together with the treatment approaches described in the previous blogs we have designed drinkbreak to be as effective as we can.  This is a treatment model based on good science and lots of clinical experience.  The final piece of the jigsaw has been to design an intervention that makes best use of the new fields of eHealth and implementation science.

We will pick up the story in the next edition of the blog.