Brief Intervention Reduces Unhealthy Alcohol Use in Veterans

As the 3rd leading cause of preventable death in the U.S., unhealthy alcohol use is often screened for during routine healthcare.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Meta-analyses have shown that brief interventions following screening can help reduce drinking among primary care patients, but it can be difficult to effectively implement these interventions due to logistical barriers.

The Veterans Health Administration (VA), screens over 90% of outpatient clients for unhealthy alcohol use and has created several initiatives to promote brief intervention for these patients.

This study evaluates the implementation of this brief intervention protocol in the VA to determine its effectiveness at changing drinking patterns among patients.

HOW WAS THIS STUDY CONDUCTED?

This study by Williams and colleagues was a naturalistic investigation of the effectiveness of a screening and brief intervention program for unhealthy alcohol use in the Veterans Administration (VA) for post military veterans. The authors used data from VA outpatients receiving care in 30 medical centers in the northern and western U.S. Patients were considered “regular users of care” if they received two documented alcohol screens at least 270 days apart between January 2004 and December 2008.

The Veterans Administration (VA) protocol used the short, 3-item version of the Alcohol Use Disorders Identification Test (AUDIT-C) to assess for unhealthy alcohol use. The VA performance measure required brief intervention for patients scoring a 5 or greater on the AUDIT-C. Because this study evaluated the VA brief intervention performance measure in the earliest phases of implementation, only patients that screened positive for unhealthy alcohol use within the first six months of the program (between October 2007 and April 2006) were included in analyses. Unhealthy alcohol use severity was then categorized based on score as mild (5), moderate (6-7), severe (8-9), and very severe (10-12).

Patients were considered to have received a documented brief intervention if they received advice to reduce or abstain from drinking between initial and follow-up AUDIT-C screens. The main outcome, resolution of unhealthy alcohol use, was defined as scoring 5 or less on the follow-up AUDIT-C screen and having at least a 2-point reduction in score.

WHAT DID THIS STUDY FIND?

Of the 269,937 regular users of care receiving an initial AUDIT-C screen during the first 6 months of brief intervention implementation, 22,214 (8%) had a score greater than or equal to 5 (i.e., unhealthy alcohol use). Only 6210 (28%) of these patients had a follow-up screen and thus were included in the analysis. Of these, 1751 (28%) received a documented brief intervention. The amount of documented brief interventions varied considerably by facility with 0 to 68% of patients receiving a brief intervention.

Seven of the 30 facilities had less than 10% of patients receive a brief intervention.

Patients receiving a brief intervention were more likely to be older, use tobacco, have more severe unhealthy alcohol use, have a high level of physical comorbidity, mental health conditions and other substance use disorders than those who did not receive a brief intervention.

At follow-up screening, 2922 (47%) of all patients screened at both time points resolved their unhealthy alcohol use with an average decrease in AUDIT-C score of 2.63. Forty-eight percent of patients receiving a brief intervention resolved unhealthy alcohol use and 47% of patients not receiving a brief intervention resolved unhealthy alcohol use. There was no significant difference in the rate of unhealthy alcohol use resolution between these two groups.

Because screening and brief intervention is designed primarily to target individuals with unhealthy alcohol use not rising to the level of substance use disorder, the authors performed several other analyses to determine if individuals with less severe unhealthy alcohol use may have benefitted from the screening and brief intervention. However, outcomes for each group remained similar for those with and without brief intervention even when looking at patients only with AUDIT-C < 8, patients without documented alcohol use disorder, and patients who had not received Veterans Administration (VA) addiction treatment services in the past year.

Among patients at 30 Veterans Administration (VA) medical centers, rates of documented brief intervention were low (28%) and varied by facility (0 to 68%) despite all patients in this study meeting criteria to receive a brief intervention. However, regardless of whether or not a brief intervention was documented, almost half of patients resolved unhealthy alcohol use at follow-up.

This finding implies the need for improvement and standardization of brief intervention protocols.

Although there are several nuances here, including aggregating participants from four separate studies, this study is an important addition to the adolescent treatment/recovery literature in understanding unique clinical profiles and needs.

Patients with certain characteristics (e.g., more severe alcohol use and comorbidities) were more likely to receive a documented brief intervention. Further research is needed to understand why this was the case. Since there was no difference in rates of unhealthy alcohol use resolution between groups, there may be an effect of the screening instrument itself such that patients may decrease alcohol intake following screening alone. This kind of effect from simply being asked about one’s alcohol use has been shown before; it may help people think more deeply about how alcohol is affecting their health and consequently cause them to make changes in their drinking.

WHY IS THIS STUDY IMPORTANT?

The Veterans Administration (VA) is the largest integrated healthcare system in the U.S., providing services for over 5 million patients annually.

If brief intervention is successful in this setting, other systems of care may be able to adapt approaches from the VA’s model.

The AUDIT-C is a common screening tool for unhealthy alcohol use in clinical practice. Since this study used a cutoff of 5 for unhealthy alcohol use in this particular population (i.e. Veterans, Military), results may not generalize to other clinical settings which often use a cutoff of ≥3 for women and ≥4 for men. Brief interventions have previously been proven effective in primary care settings, so there may be specific challenges to implementation when working with a large healthcare system like the VA and populations with high rates of substance use issues.

LIMITATIONS

As an observational study, the results are correlational in nature, without a control group condition, and despite controlling for confounding variables in analyses, there is still the possibility that some other factor caused changes in drinking. This means that there may be other unmeasured variables that cannot be controlled for in statistical analysis that could partially explain the results of this study.
With a low follow-up rate (28%), analyses may have been underpowered to identify an effect of brief intervention on the resolution of unhealthy alcohol use.
It is also unknown if this 28% are representative of all clients at the Veterans Administration (VA).
Since these data do not provide detailed information on intensity of brief interventions, it is unknown how this may have impacted its effectiveness.

NEXT STEPS

Regarding implementing brief intervention protocols in the clinical setting, this study focused on the early stages of the implementation, so the analysis should be repeated in the future to determine if the program has become more effective and broadened its reach over time.

BOTTOM LINE

For individuals & families seeking recovery: Unhealthy alcohol use can range from risky drinking to severe alcohol use disorder. While brief intervention following screening did not appear to be effective in this study, previous studies have shown a benefit among primary care patients. Additional treatment may be necessary if your alcohol use is more severe (i.e., higher score on screening test such as the AUDIT-C).
For scientists: This study was performed in the earliest phase of program implementation, so it is necessary to determine if the program has become more effective and broadened its reach over time.
For policy makers: This study shows the need for further testing of screening and brief interventions in real-world clinical settings in order to better understand the challenges facing successful implementation. For example, clinicians in the Veterans Administration (VA) have busy schedules and competing interests so they may not have the capacity to follow protocols precisely. The degree of training, oversight, and monitoring that is standard in randomized controlled trials may not be as available when implementing screening and brief interventions in large health systems like the Veterans Administration (VA) . Determining to what degree training, supervision, and performance monitoring may enhance implementation and improve patients outcomes remains to be evaluated.
For treatment professionals and treatment systems: In the current study, only 28% of patients who screened positive for alcohol use disorder received a brief intervention. When offering screening for alcohol use, it may be helpful to develop a protocol so that all patients who fit the criteria for unhealthy alcohol use receive a brief intervention before their appointment is over.