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Article Excerpt
Hazardous and harmful alcohol use is prevalent in the United States and can lead to serious health risks for the individual and create a costly burden on the health care system. Research supports the use of brief interventions designed to reduce hazardous and harmful drinking. This article explores the fit of these brief interventions with integrative health care models within the context of the United States' health care system. A literature review was conducted of alcohol brief interventions empirically evaluated for application in primary care and published within the last 10 years. There are several individual elements of brief interventions that match models of integrated health care; however, there are also significant inconsistencies. These inconsistencies are discussed in relation to three domains: (1) level of communication between providers, (2) delivery of the intervention, and (3) translation into practice. In addition, suggestions for future research and program development are provided to help address some of the barriers to implementation.
Keywords: alcohol, brief interventions, integrated health care, primary care, review
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Alcohol-related consequences pose serious health risks to individuals and are costly to United States' economy (Schneider Institute for Health Policy, 2001). Thus, it is a health care priority to address the treatment needs of hazardous and harmful drinkers (Institute of Medicine, 1990). A "hazardous" drinker is defined as a person whose drinking is associated with a risk for alcohol problems, while a "harmful" drinker is defined as someone who is experiencing negative consequences related to his or her alcohol use but does not meet criteria for alcohol dependence. Alcohol use was listed among the top three preventable behaviors deemed as the leading "actual causes of death" in the United States (Mokdad, Marks, Stroup, & Gerberding, 2004). Therefore, it is of major concern that hazardous and harmful drinkers are about four times more prevalent in the United States than are the more severely dependent drinkers (Reid, Fiellin, & O'Connor, 1999; Wilk, Jensen, & Havighurst, 1997), but that the specialized chemical dependence treatment system is geared to treating individuals with alcohol dependence.
Due to the associations between heavy alcohol use and a variety of health problems, individuals who drink at hazardous or harmful levels are disproportionately represented in primary care settings. Early interventions applied in this setting have the potential to substantially improve public health and to reduce the human and economic costs of heavy alcohol use by modifying the drinker's alcohol consumption before it reaches more severe levels requiring specialized alcohol treatment.
Research has shown that an efficacious intervention for the hazardous/harmful drinker is what has been called "brief intervention" (Kavanagh, Sitharthan, Spilsbury, & Vignaedra, 1999), which primarily is aimed at increasing an individual's motivation to change his or her alcohol use since it is believed that nondependent drinkers possess the skills needed to moderate their drinking (Davidson, 1991; Kavanagh et al., 1999). Six elements commonly included in brief interventions have been shown to be effective, and are commonly referred to with the acronym FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, and Self-efficacy (Bien, Miller, & Tonigan, 1993). Babor (1994) designated interventions lasting one, 5-min session as "minimal," and interventions lasting not more than three 1-hr sessions as "brief."
Several major reviews of research published in the last 20 years on the efficacy of brief interventions for the modification of patterns of alcohol consumption (Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005; Bien et al., 1993; Kahan, Wilson, & Becker, 1995; Moyer, Finney, Swearingen, & Vergun, 2002; Whitlock, Polen, Green, Orleans, & Klein, 2004; Wilk et al., 1997) have all concluded that brief interventions are efficacious for substantial reductions in alcohol consumption when compared to no treatment control groups. Moreover, these reductions are maintained for up to 12 months' postintervention.
Although considerable evidence exists for the efficacy of alcohol brief interventions, their actual use in clinical practice appears to be limited. Integrated health care models may provide a conceptual framework for alcohol brief interventions to be incorporated into primary care settings. Based on the biopsychosocial model (Engel, 1977), integrated health care models attempt to eliminate the separation between mind and body by increasing collaboration between behavioral health and primary care providers (PCPs) and encouraging providers to view health in a more multidimensional perspective. An increase in the communication and collaboration among providers is hypothesized to result in an increase in the detection and effective treatment of mental health disorders within primary care. A recent review provided some empirical evidence to support this view (Blount, 2003).
Because integrated health care models may provide a framework for the implementation of alcohol brief interventions in actual clinical practice, this article's goal is to assess the degree of fit between alcohol brief interventions and models of integrated health care. Therefore, we review recent studies evaluating alcohol brief interventions in primary care settings and the barriers that may be preventing the implementation of these interventions in primary care. We then describe prominent models of integrated health care and assess the degree of fit between alcohol brief interventions and models of integrated health care. In order for alcohol brief interventions to be translated into clinical practice, it is imperative that they be designed to fit within an integrated health care model. This article emphasizes the context of the United States health care system; it is important to note that health care systems vary from one country to another, and that the system dramatically affects the variables associated with the design and implementation of new programs of care.
BRIEF INTERVENTIONS IN PRIMARY CARE SETTINGS
To provide a better understanding of the fit of alcohol brief interventions targeted for primary care settings with current models of integrated health care, a literature review of randomized controlled studies of alcohol brief interventions in primary care settings was performed. Searches were made in the databases MEDLINE and PsycINFO using the following terms (or relevant combinations): "alcohol," "brief intervention," and "primary care." Given our interest in understanding how brief interventions fit within the current health care system, we limited the search to literature published in the last 10 years (from January 1996 to December 2006). Studies were included in the review if they met the following criteria: (1) utilized a randomized controlled design, (2) focused on an adult population, (3) contained a brief intervention focused specifically on harmful/hazardous alcohol use, (4) were conducted in the U.S. (at least partly), (5) were published in English, in a peer-reviewed scientific journal, and (6) took place in a primary care setting. Eleven publications on eight brief intervention protocols were identified during this time period (Burge, Amodei, Elkin, Catala, & Andrew, 1997; Curry, Ludman, Grothaus, Donovan, & Kim, 2003; Fleming, Barry, Manwell, Johnson, & London, 1997; Fleming, Manwell, Barry, Adams, & Stauffacher, 1999; Gordon et al., 2003; Maisto et al., 2001; Ockene, Adams, Hurley, Wheeler, & Hebert, 1999; Reiff-Hekking, Ockene, Hurley, & Reed, 2005; Saitz, Horton, Sullivan, Moskowitz, & Samet, 2003; Senft, Polen, Freeborn, & Hollis, 1997; WHO Brief Intervention Study Group,...
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