Michael Fleming, M.D., M.P.H., and colleagues at the University of Wisconsin Medical School in Madison report in the April 2 Journal of the American Medical Association results from Project TrEAT (Trial for Early Alcohol Treatment), the first large U.S. clinical trial to test the effectiveness of brief physician advice for intervening with nondependent problem drinkers. Supported by a grant from the National Institute on Alcohol Abuse and Alcoholism, the researchers found that brief interventions by general internists and family physicians reduced average drinks each week, excessive drinking, and binge drinking in at-risk drinkers by 20 percent or more at 1 year, twice the reduction rate of patients who did not receive the intervention. Relative to men in the control group, men in the intervention group also experienced a twofold reduction in length of hospitalizations during the followup year.
According to NIAAA Director Enoch Gordis, M.D., several studies in other countries had indicated that brief interventions held promise for the almost 20 percent of American adults who are nondependent problem drinkers: "The Project TrEAT results add to the research base for broadening clinical practice to screen for patients whose drinking practices place them at risk for developing alcohol problems so that these at-risk patients can avoid alcohol damage."
Project TrEAT used a questionnaire on drinking habits and other health behaviors to screen 2,450 problem drinkers from among 17,695 regularly scheduled patients in 17 Wisconsin clinics. Of the 2,450 patients who screened positive (men who drank more than 14 drinks or 168 grams of alcohol and women who drank more than 11 drinks or 121 grams of alcohol each week, those who drank more than 5 drinks on at least four occasions in the prior month, and those who gave two or more positive responses to a simple screening instrument), 1,705 subsequently completed face-to-face interviews in a physician's office. The 774 patients who met all inclusion criteria, including the absence of alcohol dependence symptoms, were randomized to experimental and control conditions and assessed at 6 and 12 months.
Patients in the experimental group were scheduled for two 15-minute sessions one month apart with their physicians. The intervention protocol used during those sessions included a workbook with feedback regarding current health behaviors, information on alcohol effects and problem drinking, a worksheet on drinking cues, a drinking agreement in the form of a prescription, and self-monitoring materials. Physicians were trained to administer the protocol in education sessions at each of the 17 clinics.
According to Richard Fuller, M.D., Director of Clinical and Prevention Research at NIAAA, "Screening for alcohol problems in doctors'offices is rarely done. This study provides further evidence that physicians or personnel in their offices should screen patients to identify those who may be at risk for developing alcohol problems. However, that is only the first step. It also is important to discuss screening results with the patient and advise that the patient cut down or stop drinking. In my view, those who report symptoms of alcohol dependence should be referred to specialized treatment."
Project TrEAT found large reductions in drinking practice measures at both 6 and 12 months in both men and women who received the intervention. At 12 months, men in the intervention group showed a 14 percent and women in the intervention group showed a 31 percent reduction of alcohol use. Both men and women also showed sizable reductions in excessive and binge drinking episodes. Although the control group also experienced reductions on drinking practice measures, patients in the experimental group were twice as likely to reduce their drinking by 20 percent or more.
On health care utilization measures, neither men nor women experienced significantly different numbers of emergency room visits during the course of the study or relative to intervention status. Nor was a change observed for either group in other measures of health status. However, men in the control group experienced substantially longer hospitalizations than men in the intervention group, an effect that the authors call "the first direct evidence of decreases in the utilization of U.S. health services as a result of physician intervention with problem drinkers."
Conducted in four managed care organizations and community-based private practices in urban and rural settings, Project TrEAT produced results that may be generalizable across the U.S. health care system, state the authors. For most patients, such settings are the first point of contact with the health care system and more than 90 percent of health care in the United States occurs in community-based practices.
"Since 70 percent of people in the U.S. visit their physician at least once every 2 years, brief physician advice could have enormous implications for the U.S. health care system. This trial supports the implementation of screening, assessment, and brief intervention for all patients who seek health care services in primary care community-based settings."
To arrange interviews with Dr. Fleming, telephone Judy Moore at 608/263-5561. For additional NIAAA information (including The Physicians' Guide to Helping Patients with Alcohol Problems and Alcohol Health & Research World (Vol. 18, No.2, 1994), " The Primary Care Setting: Recognition and Care of Patients with Alcohol Problems" ) and interviews telephone NIAAA's Office of Scientific Affairs at 301/443-3860. Materials also may be obtained by writing NIAAA, P.O. Box 34443, Washington, DC 20043 or visiting Internet site http://www.niaaa.nih.gov.