Screening and brief interventions for harmful alcohol use: where to now?

Current calls for primary care‐based screening and brief interventions for alcohol use should be reviewed

Alcohol continues to contribute to significant morbidity and mortality in the Australian community. It is responsible for 4.5% of total disease burden,1 and 4186 deaths in 20172 and over 144 000 hospitalisations per year.3 While levels of alcohol consumption are slowly declining, alcohol continues to be a major preventable contributor to disease and death among Australians.

Currently, over 25% of Australians report consuming alcohol at moderate or high risk levels.4

Over the past 20 years, there has been considerable research into the value of alcohol screening, brief intervention and referral for treatment (SBIRT) in primary health care as a public health measure to reduce alcohol consumption and related harms. The Alcohol Use Disorder Identification Test (AUDIT)5 was developed to assist with widespread standardised implementation of screening, and brief intervention for alcohol use disorder and has been extensively researched. More recently, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)6 was developed to address a broad range of substances.

There is good evidence based on numerous randomised controlled trials that brief interventions for alcohol use result in reductions in drinking which are at least sustained for 12 months.7 However, the actual size of the reduction in drinking has been revised down from 2007 when it was estimated that SBIRT would result in a reduction of alcohol intake by 57 g (nearly six standard drinks) per week,8 to 20 g (two standard drinks) per week.7 This reduction in effect size will inevitably affect estimates in cost‐effectiveness models.

While overall average consumption has reduced, at least based on self‐report, SBIRT has been found to have little effect on frequency of binge drinking, numbers of drinking days per week, and intensity of drinking.7 It is therefore likely to have little effect on adverse events from intoxication, the major cause of harm for younger people.

Despite strong evidence that SBIRT will result in self‐reported reduced drinking (albeit less reduction than previously thought), there have been problems with real‐world translation into practice, both on a large scale multi‐practice level9,10 and a national basis as demonstrated in Scotland.11

In terms of demonstrated effects on alcohol consumption at a population level, the most extensive program implemented so far has been Scotland’s Alcohol Strategy.11 This program aimed to deliver SBIRT across the entire primary care, emergency department and antenatal populations and was part of a suite of measures to address alcohol‐related harms in Scotland. Other measures included prohibition of multi‐buy discounting (eg, “buy five, get one free”), minimum unit pricing (unsuccessfully challenged by the Scottish Whisky Association in the Scottish Supreme Court and now being implemented), tightening of liquor licencing processes, and a tripling of investment in treatment and support services.

Subsequent measures of alcohol consumption across Scotland, Wales and England have not demonstrated any significant differences in the trajectories of alcohol consumption between these countries. Consumption has decreased in all three countries.11

Although 43% of hazardous and harmful drinkers were screened in Scotland and received brief interventions, data on exactly who was screened were difficult to collect, and screening among women attending antenatal care was only partially implemented.11 Young people were difficult to access, probably due to lower health service attendance rates.

Furthermore, a 2018 Cochrane review7 found that research into the effects of SBIRT on alcohol‐related harms, the end point of most importance, has been very limited, and was unable to reach a conclusion regarding the effect of SBIRT on alcohol‐related harms. The studies that have looked at this important issue found that there was no effect.7

In addition, recent research has cast doubt on the effectiveness of referral to treatment among the higher risk (mostly dependent) drinkers. Frost and colleagues12 reviewed the effects of brief interventions on rates of referral. They found that patients at high risk who had received a brief intervention actually had less contact with specialist addiction services in the year following the brief intervention compared with those who had not received the brief intervention.

Despite these concerns regarding effectiveness in real‐world settings, SBIRT has been recommended over the past decade in Australia by the 2009 National Preventative Health Strategy,13 and by the National Alcohol Strategy in 2019.14 Significant investment in structurally supporting SBIRT in primary care or other settings has not been forthcoming from Commonwealth or state governments.

Currently in Australia, we have a situation where the Australian National Alcohol Strategy advocates for the adoption of SBIRT. This is despite a lack of evidence that it is effective in reducing harms even in research settings, as well as a lack of evidence for its effect on reducing population levels of drinking, and evidence that it does not result in increased engagement in specialist treatment even in well resourced health systems which have identified this as a target area.

However, despite the current evidence that population‐based screening does not seem to have an effect on overall alcohol consumption, there is no denying the clinical value of addressing unhealthy alcohol consumption when identified in primary care.

The AUDIT and the ASSIST both explore relevant key areas such as frequency of use, harms and dependence, which are important for the clinician and the patient to understand and address. They enable the clinician and patient to determine the risks associated with the patient’s current drinking patterns, and to start a conversation which then enables an agreed response. They should still be promoted as tools to use when a patient has been identified as drinking excessively through normal clinical processes.

Despite current levels of alcohol‐related morbidity, the general practice environment does not support general practitioners responding to the problem. Longer consultations are insufficiently remunerated, skills development has been suboptimal, and secondary and tertiary services are not readily available when and where required.

SBIRT alone will not address the current levels of alcohol use in Australia and associated harms.

There should be increased emphasis on development of the skills base of the medical workforce at student, general practice and other specialty training levels so that clinicians can respond to hazardous and harmful alcohol and substance use effectively. Tools such as the AUDIT and the ASSIST may well have a role here.

Use of current GP Medicare items such as mental health care plans, chronic disease management plans and team care arrangements should be encouraged and facilitated to better support complex care for patients with problems relating to alcohol and substance use. In addition, addiction services should work with general practice to streamline access to advice and referrals and improve communication channels. At the same time, policy changes to reduce alcohol‐related harms should continue to be pursued.

Medical bodies including the Australian Medical Association and the Australian colleges representing physicians, GPs, surgeons, psychiatrists and emergency physicians have advocated strongly for such changes regarding alcohol, but despite this advocacy, most of the Australian community has not felt the need for major change. In general, policy change will only occur in response to community concern. The 2019 National Drug Strategy Household Survey indicated that the Australian community continues to identify methamphetamine as the drug of most concern, above alcohol. In addition, support continues to decline for reducing trading hours for pubs and clubs and increasing the minimum drinking age, as well as for all other evidence‐based measures aimed at reducing the harms nominated in the survey.4 It appears that the Australian community currently least supports the harm reduction strategies with the strongest evidence, but on the other hand supports the strategies with the least evidence.

If there were more community support, other policy changes could include reviews of pricing of alcohol and packaged liquor outlet density, further regulation of advertising of alcohol, and further changes to drink driving laws. These might include requiring a zero blood alcohol level for broader groups of drivers such as all younger drivers (ie, under 25 years of age) and drivers with previous drink driving convictions.

There should be a renewed emphasis on alcohol as a significant driver of morbidity and mortality at three levels:

• on the clinical level, renewed emphasis on education and training for medical practitioners to enable clinicians to better respond to people drinking harmfully;
• on the health care structural level, changing remuneration arrangements to better support primary care treatment for people with alcohol‐related problems should be advocated for; and
• in parallel with these changes, increased advocacy for changes to policies that reduce drinking and related harms on a population level, with particular emphasis on high risk populations.

Health professionals are generally not trained as advocates. Bringing about change, even when supported by sound evidence, is difficult and takes time. Vested interests have sophisticated advocacy skills and are well resourced. Opportunities for the development of advocacy skills at medical student and postgraduate levels should be developed and promoted. Australia remains a world leader in tobacco control. The health professions should join forces, building on the lessons from tobacco control, to change the way the Australian community views alcohol, and then lead changes in clinical practice and policy which will reduce alcohol‐related harms.