Impact of practice, provider and patient characteristics on delivering screening and brief advice for heavy drinking in primary healthcare: Secondary analyses of data from the ODHIN five-country cluster randomized factorial trial.

BACKGROUND: The implementation of primary healthcare-based screening and advice that is effective in reducing heavy drinking can be enhanced with training. OBJECTIVES: Undertaking secondary analysis of the five-country ODHIN study, we test: the extent to which practice, provider and patient characteristics affect the likelihood of patients being screened and advised; the extent to which such characteristics moderate the impact of training in increasing screening and advice; and the extent to which training mitigates any differences due to such characteristics found at baseline. METHODS: A cluster randomized factorial trial involving 120 practices, 746 providers and 46 546 screened patients from Catalonia, England, the Netherlands, Poland, and Sweden. Practices were randomized to receive training or not to receive training. The primary outcome measures were the proportion of adult patients screened, and the proportion of screen-positive patients advised. RESULTS: Nurses tended to screen more patients than doctors (OR = 3.1; 95%CI: 1.9, 4.9). Screen-positive patients were more likely to be advised by doctors than by nurses (OR = 2.3; 95%CI: 1.4, 4.1), and more liable to be advised the higher their risk status (OR = 1.9; 95%CI: 1.3, 2.7). Training increased screening and advice giving, with its impact largely unrelated to practice, provider or patient characteristics. Training diminished the differences between doctors and nurses and between patients with low or high-risk status. CONCLUSIONS: Training primary healthcare providers diminishes the negative impacts that some practice, provider and patient characteristics have on the likelihood of patients being screened and advised. Trial registration ClinicalTrials.gov. Trial identifier: NCT01501552.

Screening for At-Risk Alcohol Consumption in Primary Care: A Randomized Evaluation of Screening Approaches.

AIMS: The aim of the study was to explore the relative efficiency and effectiveness of targeted versus universal screening for at-risk alcohol use in a primary care population in the UK. METHODS: The study was a randomized evaluation of screening approach (targeted versus universal) for consecutive attendees at primary care aged 18 years or more. Targeted screening involved screening any patient attending with one of the targeted presentations, conditions associated with excessive alcohol consumption: mental health, gastrointestinal, hypertension, minor injuries or a new patient registration. In the universal arm of the study all presentations in the recruitment period were included. Universal screening included all patients presenting to allocated practices. RESULTS: A total of 3562 potential participants were approached. The odds ratio of being screen positive was higher for the targeted group versus the universal group. Yet the vast majority of those screening positive in the universal group of the study would have been missed by a targeted approach. A combination of age and gender was a more efficient approach than targeting by clinical condition or context. CONCLUSIONS: While screening targeted by age and gender is more efficient than universal screening, targeting by clinical condition or presentation is not. Further universal screening is more effective in identifying the full range of patients who could benefit from brief alcohol interventions, and would therefore have greater public health impact. TRIAL REGISTRATION: Current Controlled Trials ISRCTN06145674.

Alcohol Consumption, Early-Onset Drinking, and Health-Related Consequences in Adolescents Presenting at Emergency Departments in England.

PURPOSE: Globally, alcohol use is the leading cause of ill health and life years lost in adolescents, although its clinical impact is often overlooked, particularly in England where most research is based in schools. This study aims to examine the prevalence of alcohol consumption and the association between alcohol consumption and age of onset with health and social consequences among adolescents presenting to emergency departments (EDs). METHODS: Consecutive attenders (n = 5,576) aged 10-17 years at 10 EDs were included. Information was collected on general health and functioning, quality of life, alcohol use, and alcohol-related health and social consequences. RESULTS: Nearly 40% of adolescents reported the consumption of alcohol that was more than a sip in their lifetime. Age of the first alcohol consumption before the age of 15 years was associated with tobacco use (p < .001), lower quality of life (p = .003), and evidence of an alcohol use disorder (p = .002). It was also associated with general social functioning (problems with conduct p = .001 and hyperactivity p = .001) and alcohol-related health and social consequences (accident p = .046, problems with a parent p = .017, school p = .0117, or police p = .012). CONCLUSIONS: Rates of alcohol consumption in adolescents presenting to the ED were similar to those reported in schools in England and globally. Associations of alcohol consumption and earlier onset of drinking with poorer health and social functioning were observed. The ED can offer an opportunity for the identification of hazardous alcohol use in adolescents.

Multicentre individual randomised controlled trial of screening and brief alcohol intervention to prevent risky drinking in young people aged 14-15 in a high school setting (SIPS JR-HIGH): study protocol.

INTRODUCTION: Drinking has adverse impacts on health, well-being, education and social outcomes for adolescents. Adolescents in England are among the heaviest drinkers in Europe. Recently, the proportion of adolescents who drink alcohol has fallen, although consumption among those who do drink has actually increased. This trial seeks to investigate how effective and efficient an alcohol brief intervention is with 11-15 years olds to encourage lower alcohol consumption. METHODS AND ANALYSIS: This is an individually randomised two-armed trial incorporating a control arm of usual school-based practice and a leaflet on a healthy lifestyle (excl. alcohol), and an intervention arm that combines usual practice with a 30 min brief intervention delivered by school learning mentors and a leaflet on alcohol. At least 30 schools will be recruited from four regions in England (North East, North West, London, Kent and Medway) to follow-up 235 per arm. The primary outcome is total alcohol consumed in the last 28 days, using the 28 day Timeline Follow Back questionnaire measured at the 12-month follow-up. The analysis of the intervention will consider effectiveness and cost-effectiveness. A qualitative study will explore, via 1:1 in-depth interviews with (n=80) parents, young people and school staff, intervention experience, intervention fidelity and acceptability issues, using thematic narrative synthesis to report qualitative data. ETHICS AND DISSEMINATION: Ethical approval was granted by Teesside University. Dissemination plans include academic publications, conference presentations, disseminating to local and national education departments and the wider public health community, including via Fuse, and engaging with school staff and young people to comment on whether and how the project can be improved. TRIAL REGISTRATION TRIAL: ISRCTN45691494; Pre-results.

Medical professionals' perspectives on prescribed and over-the-counter medicines containing codeine: a cross-sectional study.

OBJECTIVES: To explore prescribing practitioners' perspectives on prescribed codeine use, their ability to identify dependence and their options for treatment in the UK. DESIGN: Cross-sectional design using a questionnaire containing closed-ended and open-ended items. SETTING: A nationally representative sample of prescribing professionals working in the UK. PARTICIPANTS: 300 prescribing professionals working in primary care and pain settings. RESULTS: Participants stated that they regularly reviewed patients prescribed codeine, understood the risks of dependence and recognised the potential for codeine to be used recreationally. Over half the participants felt patients were unaware of the adverse health consequences of high doses of combination codeine medicines. One-quarter of participants experienced patient resentment when asking about medicines containing codeine. Just under 40% of participants agreed that it was difficult to identify problematic use of codeine without being informed by the patient and did not feel confident in identification of codeine dependence. Less than 45% of all participants agreed that codeine dependence could be managed effectively in general practice. Slow or gradual withdrawal was the most popular suggested treatment in managing dependence. Education and counselling was also emphasised in managing codeine-dependent patients in primary care. CONCLUSIONS: Communication with patients should involve assessment of patient understanding of their medication, including the risk of dependence. There is a need to develop extra supports for professionals including patient screening tools for identifying codeine dependence. The support structure for managing codeine-dependent patients in primary care requires further examination.

The effectiveness of electronic screening and brief intervention for reducing levels of alcohol consumption: a systematic review and meta-analysis.

BACKGROUND: Electronic screening and brief intervention (eSBI) has been shown to reduce alcohol consumption, but its effectiveness over time has not been subject to meta-analysis. OBJECTIVE: The current study aims to conduct a systematic review and meta-analysis of the available literature to determine the effectiveness of eSBI over time in nontreatment-seeking hazardous/harmful drinkers. METHODS: A systematic review and meta-analysis of relevant studies identified through searching the electronic databases PsychINFO, Medline, and EMBASE in May 2013. Two members of the study team independently screened studies for inclusion criteria and extracted data. Studies reporting data that could be transformed into grams of ethanol per week were included in the meta-analysis. The mean difference in grams of ethanol per week between eSBI and control groups was weighted using the random-effects method based on the inverse-variance approach to control for differences in sample size between studies. RESULTS: There was a statistically significant mean difference in grams of ethanol consumed per week between those receiving an eSBI versus controls at up to 3 months (mean difference -32.74, 95% CI -56.80 to -8.68, z=2.67, P=.01), 3 to less than 6 months (mean difference -17.33, 95% CI -31.82 to -2.84, z=2.34, P=.02), and from 6 months to less than 12 months follow-up (mean difference -14.91, 95% CI -25.56 to -4.26, z=2.74, P=.01). No statistically significant difference was found at a follow-up period of 12 months or greater (mean difference -7.46, 95% CI -25.34 to 10.43, z=0.82, P=.41). CONCLUSIONS: A significant reduction in weekly alcohol consumption between intervention and control conditions was demonstrated between 3 months and less than 12 months follow-up indicating eSBI is an effective intervention.

Alcohol screening and brief intervention for adolescents: the how, what and where of reducing alcohol consumption and related harm among young people.

AIM: The aim of the study was to explore the evidence base on alcohol screening and brief intervention for adolescents to determine age appropriate screening tools, effective brief interventions and appropriate locations to undertake these activities. METHODS: A review of existing reviews (2003-2013) and a systematic review of recent research not included in earlier reviews. RESULTS: The CRAFFT and AUDIT tools are recommended for identification of 'at risk' adolescents. Motivational interventions delivered over one or more sessions and based in health care or educational settings are effective at reducing levels of consumption and alcohol-related harm. CONCLUSION: Further research to develop age appropriate screening tools needs to be undertaken. Screening and brief intervention activity should be undertaken in settings where young people are likely to present; further assessment at such venues as paediatric emergency departments, sexual health clinics and youth offending teams should be evaluated. The use of electronic (web/smart-phone based) screening and intervention shows promise and should also be the focus of future research.

Identifying the gap between need and intervention for alcohol use disorders in Europe.

AIMS: A literature review of existing research on the prevalence of alcohol use disorders (AUDs) and availability of alcohol interventions in Europe was conducted. The review also explored what is known about the gap between need and provision of alcohol interventions in Europe. METHODS: The review search strategy included: (i) descriptive studies of alcohol intervention systems in Europe; (ii) studies of alcohol service provision in Europe; and (iii) studies of prevalence of AUD and alcohol needs assessment in Europe. RESULTS: Europe has a relatively high level of alcohol consumption and the resulting disabilities are the highest in the world. Most research on implementation of alcohol interventions in Europe has been restricted to screening and brief interventions. Alcohol needs assessment methodology has been developed but has not been applied in comparative studies across countries in Europe. CONCLUSIONS: This review points to key gaps in knowledge related to alcohol interventions in Europe. There is a lack of comparative data on variations in alcohol treatment systems across European countries and there is also a lack of comparative data on the prevalence of alcohol use disorders across European countries and the relative gap between need and access to treatment. The forthcoming Alcohol Measures for Public Health Research Alliance (AMPHORA) research project work package on 'Early identification and treatment' aims to address these gaps.

Mephedrone, new kid for the chop?

AIMS: Mephedrone (4-methylmethcathinone) is a novel synthetic stimulant drug that has recently become popular in the United Kingdom and elsewhere in Europe. It has a short history of human consumption and little is known about its prevalence and pattern of use. This study aimed to obtain preliminary data on its use and effects among dance drug users in the United Kingdom. DESIGN: Cross-sectional anonymous online survey of mephedrone recruited as part of larger study exploring patterns of drug use among those associated with the dance music scene. Setting UK-based dance music and clubbing website. PARTICIPANTS: A total of 947 ever users of mephedrone recruited as part of a wider study on dance drug use patterns. MEASUREMENTS: Assessment of demographics, ever and current drug use and patterns and selected effects following use of mephedrone. FINDINGS: A total of 947 (41.3%) of 2295 participants reported ever having used mephedrone. Mephedrone was the sixth most frequently used drug in the last month after tobacco, alcohol, cannabis, cocaine and 3,4-methylenedioxymethamphetamine (MDMA). Users were typically younger (P < 0.001) and male (P < 0.01); 15.1% reported using weekly or more frequently; 49.5% reported using between 0.5 and 1 g during a typical session; 69.5% reported that intranasal use was the most common route of use. Intranasal use was associated with increased abuse liability; 54.6% of those who have also used cocaine reported that the quality of the high obtained with mephedrone was better, with those using intranasally being significantly more likely than those who took the drug orally to report that mephedrone was more addictive (P < 0.02) and more risky (P < 0.02) than cocaine. Route of use was unrelated to any stimulant-related adverse effect apart from palpitations (P < 0.005). CONCLUSIONS: Mephedrone appears to be used primarily intranasally and to have comparable abuse potential to cocaine, with more than half those who use both reporting that mephedrone gives a better quality high.

Screening and brief interventions for hazardous and harmful alcohol use in probation services: a cluster randomised controlled trial protocol.

BACKGROUND: A large number of randomised controlled trials in health settings have consistently reported positive effects of brief intervention in terms of reductions in alcohol use. However, although alcohol misuse is common amongst offenders, there is limited evidence of alcohol brief interventions in the criminal justice field. This factorial pragmatic cluster randomised controlled trial with Offender Managers (OMs) as the unit of randomisation will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in probation and different intensities of brief intervention to reduce excessive drinking in probation clients. METHODS AND DESIGN: Ninety-six OMs from 9 probation areas across 3 English regions (the North East Region (n = 4) and London and the South East Regions (n = 5)) will be recruited. OMs will be randomly allocated to one of three intervention conditions: a client information leaflet control condition (n = 32 OMs); 5-minute simple structured advice (n = 32 OMs) and 20-minute brief lifestyle counselling delivered by an Alcohol Health Worker (n = 32 OMs). Randomisation will be stratified by probation area. To test the relative effectiveness of different screening methods all OMs will be randomised to either the Modified Single Item Screening Questionnaire (M-SASQ) or the Fast Alcohol Screening Test (FAST). There will be a minimum of 480 clients recruited into the trial. There will be an intention to treat analysis of study outcomes at 6 and 12 months post intervention. Analysis will include client measures (screening result, weekly alcohol consumption, alcohol-related problems, re-offending, public service use and quality of life) and implementation measures from OMs (the extent of screening and brief intervention beyond the minimum recruitment threshold will provide data on acceptability and feasibility of different models of brief intervention). We will also examine the practitioner and organisational factors associated with successful implementation. DISCUSSION: The trial will evaluate the impact of screening and brief alcohol intervention in routine probation work and therefore its findings will be highly relevant to probation teams and thus the criminal justice system in the UK.Ethical approval was given by Northern & Yorkshire REC. TRIAL REGISTRATION NUMBER: ISRCTN 19160244.

Screening and brief interventions for hazardous alcohol use in accident and emergency departments: a randomised controlled trial protocol.

BACKGROUND: There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments. METHODS/DESIGN: The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation. DISCUSSION: This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments. TRIAL REGISTRATION: ISRCTN 93681536.