Intervention Review

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Interventions for preventing injuries in problem drinkers

  1. Tho Bella Dinh-Zarr1,*,
  2. Cynthia W Goss2,
  3. Elizabeth Heitman3,
  4. Ian G Roberts4,
  5. Carolyn DiGuiseppi2

Editorial Group: Cochrane Injuries Group

Published Online: 19 JUL 2004

Assessed as up-to-date: 31 MAR 2004

DOI: 10.1002/14651858.CD001857.pub2


How to Cite

Dinh-Zarr TB, Goss CW, Heitman E, Roberts IG, DiGuiseppi C. Interventions for preventing injuries in problem drinkers. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD001857. DOI: 10.1002/14651858.CD001857.pub2.

Author Information

  1. 1

    MAKE ROADS SAFE - The Campaign for Global Road Safety, Road Safety, FIA Foundation, Washington , DC, USA

  2. 2

    University of Colorado Denver, Colorado Injury Control Research Center, Colorado School of Public Health, Denver, CO, USA

  3. 3

    Vanderbilt University Medical Center, Center for Clinical and Research Ethics, Nashville, TN, USA

  4. 4

    London School of Hygiene & Tropical Medicine, Cochrane Injuries Group, London, UK

*Tho Bella Dinh-Zarr, Road Safety, FIA Foundation, MAKE ROADS SAFE - The Campaign for Global Road Safety, 336 13th Street, NE, Washington , DC, 20002, USA. dinhzarr@dinhzarr.org.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 19 JUL 2004

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms

Alcohol consumption has been linked with injuries and deaths incurred through motor vehicle crashes, falls, drowning, fires and burns, and violence (NCIPC 2001). In the United States, alcohol consumption contributes to 38% of motor vehicle crash fatalities, 40% of deaths in residential fires, and 25% to 50% of adolescent and adult deaths associated with water recreation (NCIPC 2001). A strong association has been found between alcoholism and domestic violence (O'Farrell 1995, Cunradi 2002). Even moderate alcohol consumption has been associated with increases in injuries and deaths from trauma (Andreasson 1988, Vinson 1995). Problem drinkers who do not meet definitions for alcohol dependence are responsible for the majority of alcohol-related morbidity and mortality in the general population (IOM 1990). In the United States, the burden of alcohol-related diseases and injuries on emergency department is now three times greater than previously reported, with alcohol-related visits to emergency departments from 1992-2001, averaging 7.6 million visits per year (McDonald 2004). Nearly half of the global burden of alcohol-related mortality is attributable to unintentional and intentional injury (Rehm 2003). Based on estimates of global injury mortality and its contributors (Rehm 2003), alcohol-related injuries world-wide may cause several million deaths each year.

 

Why it is important to do this review

Numerous randomized controlled trials have evaluated a diverse range of interventions to reduce alcohol dependence, abuse or consumption: pharmacotherapy; individual, couple, and group counseling; exercise; acupuncture; controlled drinking; brief educational interventions (alcohol intake assessment and provision of information and advice); and other in- and out-patient therapies and combinations of treatments. Most such trials have measured effects of treatment on alcohol consumption and maintenance of abstinence. Many trials have also evaluated the effects of treatment on a wide variety of negative consequences linked directly or indirectly to drinking (e.g. hospitalizations, social or occupational maladjustment) (Babor 1994). Because of the increased risk of injuries associated with problem drinking, we undertook a systematic review to evaluate the effectiveness of interventions for problem drinking in preventing injuries.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms

To assess by systematic review the effect of interventions for problem drinking on injuries and their antecedents.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomized controlled trials.

 

Types of participants

People diagnosed with alcohol dependence, alcohol abuse, or hazardous use of alcohol, all of which are considered to be 'problem drinking'.

 

Definitions

  • Alcohol dependence (i.e. "alcoholism", "alcohol addiction") involves impaired control over drinking, manifested by physiological addiction to alcohol and/or serious disturbances of health, work, social or recreational activities, or other areas of functioning related to alcohol use (DSM-IV-TR 2000).
  • Alcohol abuse (i.e. "harmful drinking") involves serious disturbances of health, work, or other areas of functioning related to alcohol use, without satisfying the criteria for alcohol dependence (DSM-IV-TR 2000).
  • Hazardous use of alcohol, such as binge or chronic heavy drinking, places asymptomatic drinkers at risk for future health and other problems (USPSTF 1996).

For the purposes of this review, we refer to alcohol dependence, alcohol abuse, and hazardous use of alcohol as "problem drinking."

 

Types of interventions

Interventions designed to reduce or eliminate alcohol consumption, prevent hazardous use of alcohol, or prevent injuries or their antecedents (e.g. falls, motor vehicle crashes).

 

Types of outcome measures

Injuries and injury deaths, or their antecedents (e.g. falls, motor vehicle crashes, suicide attempts).

 

Search methods for identification of studies

Eligible trials were identified by searching relevant computerized medical databases (see below), reviewing reference lists of relevant trials, contacting national and international agencies for information about unpublished studies, and asking authors of relevant trials to identify additional published or unpublished trials.

These electronic searches were updated in May 2002. ITRD, TRANSDOC, and TRIS have been combined into a single database, TRANSPORT. This database was searched for the update. Bibliographies of eligible trials were reviewed to identify additional studies.

 

Electronic searches

Twelve electronic databases were searched:

  • MEDLINE (1966 to March 2002)
  • EMBASE (1982 to May 2002)
  • CENTRAL (The Cochrane Library 2002, Issue 2)
  • PsycINFO (1967 to Feb 2002)
  • Cumulative Index to Nursing and Allied Health (CINAHL) (1982 to October 1996)
  • Educational Resource Information Center (ERIC) (1966 to December 1996)
  • Dissertation Abstracts International (1861 to November 1996)
  • International Transport Research Documentation (ITRD) (1972 to January 1997)
  • Transport 1988 to 2002/03 (which includes TRANSDOC; a publication of the European Conference of Ministers of Transport) and ((TRIS; Transportation Research Information Service)
  • International Bibliography of the Social Sciences (IBSS) (1961 to January 1997)
  • Index of Scientific & Technical Proceedings (ISTP) (1982 to January 1997)

The search strategy is described in Appendix 1.

 

Searching other resources

We handsearched abstracts from the Transport Research Laboratory Database of Worldwide Published Information and relevant conference proceedings at the Transport Research Laboratory Library (United Kingdom).

To find other eligible published or unpublished trials, we contacted and received responses from the:

  • National Highway Traffic Safety Administration and the National Institute for Alcohol Abuse and Alcoholism (United States)
  • Federal Office of Road Safety (Australia)
  • Addiction Research Foundation (Canada)
  • Transport Research Laboratory (United Kingdom)
  • University of Auckland's Injury Prevention Research Centre (New Zealand)
  • Väg-och Trafik-Institutet (Sweden)

 

Data collection and analysis

 

Selection of studies

One researcher first reviewed titles and abstracts to identify potentially relevant trials, using the selection criteria of study design, participants and interventions. Studies that clearly failed to meet these three inclusion criteria were excluded. Those that met these criteria or could not be definitely excluded were obtained in full text, to exclude those that did not meet at least these first three inclusion criteria. We contacted the corresponding authors of all remaining studies to identify additional potentially relevant trials and to request further details to determine eligibility (if required). If studies met the first three inclusion criteria but did not report collecting injury-related outcome measures (selection criterion four), we asked the authors to provide any unpublished data on such outcomes. We attempted to contact additional authors (by mail, telephone, and Internet search) when corresponding authors were deceased or could not be traced.

 

Data extraction and management

Two reviewers independently extracted data and rated the quality of allocation concealment for each eligible study. We extracted data on: the number and description of participants, type of intervention, duration of follow-up, method of allocation concealment, and outcomes evaluated. We assessed the quality of allocation concealment as follows: an 'A' rating signified adequate measures to conceal allocation (e.g. central randomization; serially numbered, opaque, sealed envelopes); a 'B' rating signified unclear adequacy of allocation concealment (e.g. no mention of allocation concealment, or insufficient description of allocation concealment, such as "sealed envelopes" ); and a 'C' rating signified inadequately concealed allocation (e.g. alternation; open list of random numbers) (Schulz 1995). There was 100% agreement in the allocation concealment ratings. Studies that would have received a 'C' rating based on the use of quasi-random allocation were ineligible under our inclusion criteria.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

 

Results of the search

Of the 7014 published and unpublished studies identified by our search strategies in the original review, 569 (8.1%) were potentially relevant, based on title or abstract. After full text review, nine trials met all four inclusion criteria (Brown 1980, Reis 1982a, Reis 1982b, Walsh 1991, Anderson 1992, Öjehagen 1993, Mann 1994, Barber 1995, Sitharthan 1996). An additional 314 met the first three inclusion criteria. For 23 of these 314 trials (7%), we could not determine whether injury-related outcomes had been measured, because all authors were either untraceable or deceased. The authors of 119 (41%) of the remaining 291 studies responded to our requests for further information. From these responses, we identified an additional nine eligible completed studies (Gallant 1968, Landrum 1981, McCrady et al 1982, Fitzgerald 1985, Potamianos 1986, Kuchipudi 1990, WHO BISG 1996, Toteva 1996, Sitharthan 1997). Two trials (McCrady et al 1982, Anderson 1992) were subsequently excluded because their 'injury' outcome measures were found to include other outcomes not specifically related to injury (i.e. criminal behavior and alcohol-related illness, respectively) that could not be separated from the injury data. The injury-related data for three studies were published in government reports (Reis 1982a, Reis 1982b, Landrum 1981) and we obtained unpublished injury data from the authors of four studies (Barber 1995, Gallant 1968, Fitzgerald 1985, Kuchipudi 1990).

The updated database searches identified 52 potentially eligible studies for full-text review; five eligible trials were found, one of which had been in progress at the time of the original review. Review of bibliographies identified one additional trial. Thus, six trials met all inclusion criteria (Gentilello 1999, Monti 1999, Fleming 1997, Fleming 1999, Kristenson 2002, and Longabaugh 2001). We also identified two published follow-up reports to Fleming 1997 (Manwell 2000, Fleming 2002). Long-term follow-up from the trial by Öjehagen et al (Ojehagen 1993) has been presented at an international conference in Sweden (Öjehagen 1997). We identified one eligible study in progress (written communication: Bohn M, University of Wisconsin Medical School, Madison, Wisconsin, May 5, 2004). A trial previously identified as in progress did not collect injury-related outcomes as planned because the available motor vehicle crash records were insufficient; this trial was therefore excluded as ineligible (Wells-Parker 2002).

A total of 23 eligible trials have therefore been identified (See Table of included studies and List of on-going studies), of which 22 have been completed, 17 have reported results for injury-related outcomes, and 16 have reported numerical data for the relevant outcomes.

 

Risk of bias in included studies

 

Allocation

Four completed trials received an 'A' rating for allocation concealment (Reis 1982a, Reis 1982b, Fitzgerald 1985, Potamianos 1986). The remaining completed trials received a 'B' rating, in most cases because the method of randomization was unspecified and the information was not obtainable from the authors.

In the trial by Fitzgerald and Mulford (Fitzgerald 1985), the number of subjects differed markedly between the two study groups at Center A. The author notes that originally the study had two experimental groups at Center A, 'hospital-initiated telephone aftercare' and 'patient-initiated telephone aftercare', in addition to a 'no aftercare' control group. Because 42 of 43 subjects randomly assigned to 'patient-initiated aftercare' did not in fact initiate any contacts, all 43 patients were combined with the control group in the analysis. Random allocation to the first experimental group was maintained. The author states that there was little impact on their effect estimates regardless of whether these subjects were included or excluded from the control group (personal communication, HA Mulford, September 1997).

 

Effects of interventions

The 23 completed trials evaluated a diverse group of interventions, patient populations, and injury outcomes. The most common intervention studied was brief counseling for problem drinking, which was evaluated in nine trials. The data from these trials, when available, have been combined quantitatively where appropriate. Due to the diversity of interventions, populations, and outcomes studied in the other trials, no attempt was made to combine their results. Effects of intervention on abstinence, alcohol consumption, and alcohol-impaired driving are shown in the notes section of the Table of included studies.

 

Mortality

Eight completed trials collected injury mortality outcomes. Twenty-seven total deaths were reported in the seven trials for which data were available (Fleming 2002, Gallant 1968, Kristenson 2002, Kuchipudi 1990, Mann 1994, Öjehagen 1997, Walsh 1991).

Four trials compared intervention to no intervention. Three of these reported a reduced risk of death in the intervention group compared to the control group, although all effect estimates were imprecise due to small numbers. At 48-month follow-up, Fleming 2002 reported one suicide per 392 subjects in the intervention group and two motor vehicle crash deaths per 382 subjects in the control group (RR=0.49; 95% CI 0.04 to 5.35). Mann 1994 reported 3/220 accidental and violent deaths in the experimental group and 5/127 in the control group: relative risk (RR) 0.35; 95% confidence interval (CI) 0.08 to 1.43). Kuchipudi 1990 reported 3/59 suicides and violent deaths in the intervention group and 5/55 in the control group (RR=0.56; 95% CI 0.08 to 1.43). The fourth trial reported more deaths in the intervention than the control group. Kristenson 2002 reported one suicide per 365 persons in the intervention group and no injury deaths per 382 persons in the control group (p=0.55, Fisher's exact test). Combining data from the three trials of brief counseling that reported effects on injury-related deaths (Fleming 2002, Kristenson 2002, Kuchipudi 1990), the relative risk of death among 1555 total subjects was reduced with intervention (RR=0.65; 95% CI 0.21 to 2.00).

The other three completed trials reporting injury mortality data compared different treatment modalities, without any 'no intervention' control group. There were too few events in each of these three trials (none in Gallant 1968, two in Walsh 1991, five in Öjehagen 1997) to identify differences in the effects of specific treatment modalities on injury deaths. At 9 years follow-up, Öjehagen 1997 reported three suicides among 36 participants who received one year of multi-modal behavioural therapy versus two suicides among 36 participants who received a year of psychiatric therapy (RR=1.50; 95% CI 0.27 to 8.45), although the effect estimate was imprecise due to small numbers.

Data were not available for Toteva and Milanov (Toteva 1996), which reported collecting data on suicides.

 

Non-fatal injuries

Eighteen completed trials collected data on non-fatal injuries and their antecedents. The results from trials collecting non-fatal injury outcomes due to specifically identified causes (violence, falls, motor vehicle crashes) are summarized separately below.

Eleven trials collected data on non-fatal injuries due to all causes. Results, however, were available from only six of these trials: Kuchipudi 1990, Fitzgerald 1985, Monti 1999, Longabaugh 2001, Gentilello 1999, Fleming 1999. Three of the six trials specifically assessed alcohol-related injuries (Longabaugh 2001, Monti 1999, Fitzgerald 1985); the remainder looked at injuries regardless of relationship to alcohol use.

In five of the six trials, the intervention for problem drinking reduced the risk of injuries or accidents compared to no intervention. In four of the trials, a reduction in injury risk occurred, despite the fact that there were no beneficial effects of treatment on abstinence (Kuchipudi 1990, Fitzgerald 1985) or on alcohol consumption (Monti 1999, Longabaugh 2001) (see Notes in Table of Included Studies). Three of these reported specifically on alcohol-related injuries. Fitzgerald 1985 reported a reduction in drinking-related injuries and accidents with telephone aftercare contacts (RR=0.73; 95% CI 0.34 to 1.58). Monti 1999 found a significantly reduced risk of self-reported alcohol-related injury at 6-month follow-up among adolescents who received a brief intervention in the emergency department (21% versus 50%, adjusted OR=0.25; 95% CI 0.09 to 0.69). Longabaugh 2001 compared a motivational interview with a booster session to standard care and reported fewer mean total injuries (0.67 versus 0.72; p=0.17, one-tailed) and alcohol-related injuries (0.165 v. 0.240 mean injuries, p = 0.04, one-tailed). However, mean alcohol-related injuries after a motivational interview alone (without a booster session) were not different from mean alcohol-related injuries after standard care (data not provided, p > 0.40, one-tailed). Total injuries and injuries treated by a doctor did not differ among any of the three groups (data not shown, p>0.05). Kuchipudi 1990 reported the beneficial effect of a motivational intervention on injury-related hospitalizations (2/59 vs 3/55; RR=0.62; 95% CI: 0.11, 3.58). In the fifth trial (Gentilello 1999), both injury risk and alcohol consumption were reduced with intervention. At one-year follow-up, Gentilello 1999 found that a brief motivational intervention reduced the risk of injury requiring emergency treatment or hospital admission (adjusted hazard ratio 0.53, 95% CI 0.26 to 1.07). At three year follow-up, the risk of injury resulting in hospital readmission was also reduced (adjusted hazard ratio 0.52, 95% CI 0.21 to 1.29). Alcohol consumption was substantially reduced at 12-month follow-up (-21.8 (3.7) versus -6.7 (5.8) drinks/week, p=0.03).

In the sixth trial, Fleming 1999 implemented a brief motivational interview among adults aged > 65 years and reported that there were "no significant changes" in accidents or injuries (data were not reported), although alcohol consumption was significantly reduced with intervention.

Other trials also measured the effect of the experimental intervention on accidents (Brown 1980, Walsh 1991, Potamianos 1986) or injuries (WHO BISG 1996; Toteva 1996), but we were unable to obtain these data.

 

Non-fatal violence

Seven completed trials collected data on non-fatal violence, but data were available for only four of the trials.

All three trials evaluating intervention versus no intervention suggested a reduction in non-fatal violence with intervention (Barber 1995, Fitzgerald 1985, Fleming 2002). Barber and Crisp, using the "Pressure to Change" approach for partners of heavy drinkers, reported a reduction in 'domestic violence' (4/16 vs 3/7; RR=0.58; 95% CI 0.17 to 1.95). Fitzgerald and Mulford reported a reduction in suicide attempts with telephone aftercare contacts (4/125 vs 11/167; RR=0.48; 95% CI 0.15, 1.51). A motivational interview administered to injured problem drinkers resulted in fewer instances of arrest for assault, battery, and/or child abuse than did standard care (Fleming 2002; 8 events/1568 person-years v 11/1528 person-years; RR=0.71; 95% CI 0.29, 1.76). Two of the three trials (Fleming 2002, Barber 1995) showed a beneficial effect on drinking-related outcomes as well as on injuries. The reduction in mean drinks per week did not persist to 48 month follow-up in Fleming et al (2002), although the reduction in binge drinking episodes did. Fitzgerald 1985 found little difference in abstinence rates between the two groups (21% versus 22%).

The fourth trial (Sitharthan 1997) reported a reduced risk of committing assault after cognitive behavioral therapy compared to cue exposure therapy (0/25 vs 5/27; RR=infinity; 95% CI: 0.91, infinity) (CI shown is based on the odds ratio approximation), p=0.06. Sitharthan, however, found a greater reduction in alcohol consumption with cue exposure therapy.

Other completed trials measured the effect of intervention on aggressive behavior (Potamianos 1986), assaults (Sitharthan 1996), and criminal and domestic violence (Toteva 1996), but data were not available.

 

Falls

Kuchipudi 1990 reported the beneficial effect of a motivational intervention on falls (3/59 vs 4/55; RR=0.70; 95% CI 0.16, 2.98). No other trials specifically assessed effects of interventions for problem drinking on falls.

 

Motor vehicle crashes

Five completed trials assessed the effect of intervention on motor vehicle crashes and on injuries following motor vehicle crashes. Data were available from four of these trials.

Landrum 1981 assessed three different interventions for persons convicted of DUI (driving under the influence), compared to no intervention. Monthly probation alone, structured rehabilitation alone, and these two interventions combined were each associated with a reduced risk of motor vehicle crashes: RR=0.76 (95% CI 0.51 to 1.13), RR=0.85 (0.57 to 1.26), and RR=0.90 (0.60 to 1.35), respectively. Monthly probation and structured rehabilitation had stronger effects on motor vehicle crash injuries (RR=0.47; 95% CI 0.20 to 1.11 and RR=0.58; 95% CI 0.26 to 1.32, respectively), while the combination of probation and rehabilitation appeared to have no effect on crash-related injuries (RR=1.06; 95% CI 0.52 to 2.17). However, all effect estimates were imprecise. (Proportions with crashes and injuries in each group are shown in the Table of included studies.) Despite apparently differential effects on crashes and injuries, all four groups had similar rates of DUI repeat arrests (32%, 33%, 31%, and 33%, respectively), with the lowest repeat arrest rate in the intervention group that showed the smallest effect on crashes and related injuries (i.e. probation plus rehabilitation).

In a study of DUI first offenders (Reis 1982a), in-class education about drink driving reduced the cumulative accident rate (0.084 compared to 0.101 in controls), but there appeared to be little effect from home study (cumulative accident rate=0.098); the overall p value for the three groups was 0.58. In-class education also had a stronger effect on alcohol consumption and on DUI arrest recidivism than did home study (see Table of included studies).

In a study of DUI multiple offenders (Reis 1982b), only educational counseling combined with disulfiram therapy appeared to reduce the cumulative incidence of alcohol-related crashes and injuries (0.055) compared to no intervention (0.076). The cumulative incidence of alcohol-related crashes and injuries was higher in the groups receiving bi-weekly contacts (Cumulative incidence=0.086) and educational counseling alone (0.087) than in controls, despite the fact that counseling alone was as effective as counseling with disulfiram in reducing DUI arrest recidivism.

Fleming 2002 measured motor vehicle crashes for 48 months after administering a brief intervention to injured problem drinkers. Compared to a no-intervention group, the intervention group had fewer motor vehicles crashes resulting in fatal or non-fatal injuries or property damage (87/1568 person-years v. 105/1528 person-years, RR=0.81; 95% CI 0.61 to 1.06). Effects were greater on motor vehicle crashes with injuries (20/1568 person-years v. 33/1528, RR=0 .59; 95% CI 0.34 to 1.02) than on motor vehicle crashes with property damage only (67/1568 person-years v. 72/1528 person-years, RR=0.91; 95% CI 0.66 to 1.26). However, all effect estimates were imprecise.

Potamianos 1986 also measured the effect of community-based day center treatment on motor vehicle crashes, but these data were unavailable.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms
 

Summary of main results

Injury is a major public health problem worldwide, and alcohol is a significant contributor. The reduction of unintentional and intentional injuries due to problem drinking is, therefore, an important public health goal. Although these data are not conclusive, they do indicate that interventions for problem drinking may be effective in reducing injuries and injury deaths. In the thirteen trials that compared interventions for problem drinking to control interventions and provided outcome data, nearly all interventions showed a beneficial effect on injury-related outcomes. The estimated effect sizes were typically large, with reductions in alcohol- or drinking-related injuries ranging from 27% to 65%. Because the trial sample sizes were generally small, however (few of the trials having been designed to measure effects on injuries), the precision of most estimates was low. However, two recent studies were large enough to demonstrate statistically significant reductions in alcohol-related injuries (Longabaugh 2001, Monti 1999). The results indicate that interventions to reduce problem drinking have beneficial effects on the incidence of injuries, particularly alcohol-related injuries, and interventions could have an important effect on injury deaths.

Although reduced alcohol consumption would seem a likely mechanism for any beneficial effects of treatment on injuries, this review does not provide strong support for this mechanism. Among trials reporting beneficial effects on injuries or injury antecedents, five trials reported reduced alcohol consumption or increased abstinence (Reis 1982a, Reis 1982b, Barber 1995, Gentilello 1999, Fleming 2002), but four showed no effect on these outcomes (Fitzgerald 1985, Kuchipudi 1990, Monti 1999, Longabaugh 2001). In two of four completed trials that compared different treatment modalities and provided data on injury outcomes, there were significantly greater declines in alcohol consumption with one therapeutic modality compared to the other(s) (Sitharthan 1997, Walsh 1991). In both trials, however, the treatments that were associated with reduced injury risk were not the treatments associated with reductions in alcohol consumption. It is possible that these paradoxical results can be explained by chance, reflecting the nearly universally imprecise effect estimates, or by measurement error in the assessment of the drink- or injury-related outcomes. It is also possible that beneficial effects on injuries are mediated by other aspects of treatment for problem drinking (e.g. receipt of medical attention and social support).

Similarly, the evidence does not establish that reported reductions in unintentional injuries are due to decreases in driving while impaired by alcohol. Reis (Reis 1982a; Reis 1982b) found significant reductions in DUI recidivism rates in both of his trials, Gentilello 1999 et al reported reduced DUI violations, and Monti 1999 et al reported reductions in self-reported drinking and driving. On the other hand, Landrum 1981 and Fleming 2002 reported minimal or no effects on DUI incidence with intervention, and Kuchipudi 1990 found an increase in DUI rates with intervention.

The availability of research examining brief clinical interventions for problem drinkers is increasing. In fact, all six trials identified during the May 2002 update evaluated such interventions. Five of the seven trials that evaluated brief interventions for problem drinking, and provided results, reported reductions in injury outcomes, but akin to trials identified for the original review, the mechanisms for these reductions are unclear. Gentilello 1999, Fleming 2002, and Fleming 1999 found significant decreases in alcohol consumption; however, Fleming 1999 found no reduction in injury outcomes. Furthermore, the two trials that reported significant reductions in alcohol-related injury outcomes did not find reductions in alcohol consumption (Monti 1999, Longabaugh 2001), nor did Kuchipudi 1990 et al find any effect on abstinence despite finding reductions in injury hospitalizations and deaths. Brief interventions also had mixed effects on hazardous drinking behavior associated with injury risk: Gentilello 1999 reported reduced DUI violations and Monti reported reductions in drinking and driving, but Fleming 2002 and Kuchipudi 1990 found no or adverse effects on DUI incidence with intervention. Recently a need for medical interventions for people with alcohol problems, particularly in emergency department settings, has been emphasized (Hungerford 2003, McDonald 2004). Increased research on emergency department interventions for problem drinkers should help to identify characteristics of effective interventions for different age, sex, and other populations, as well as the mechanisms for the beneficial effects of such treatment on injury outcomes.

 

Quality of the evidence

We limited our critique of the quality of the included studies to an assessment of the quality of allocation concealment because this appears to be the most important criterion for assessing the validity of a randomized trial (Schulz 1995). Unfortunately, we were able to determine this criterion accurately in only a small proportion of the trials reviewed. Few trials reported allocation concealment in detail, and among the others, very few researchers provided us with sufficient information to assess this criterion adequately. We cannot, therefore, draw firm conclusions about quality for most of the trials.

The aim of our systematic review was to make explicit the randomized evidence on what appears to be a promising approach to tackling the problem of alcohol-related injuries. A key finding of the review is that the trials that we found reported imprecise effect estimates, and often had methodological weaknesses, indicating that this promising approach requires further research. We considered the possibility of combining the available data from these trials in a meta-analysis to increase the precision of the effect estimates. However, for the most part, this would have involved combining markedly heterogeneous groups of participants, interventions, and outcomes. In such circumstances, a meta-analysis can produce inappropriate, and even misleading, conclusions (Bailar 1997, Lancet 1997). We did attempt to quantitatively combine results from the seven trials of brief interventions. However, this was possible only for deaths, because the diversity of non-fatal injury outcomes measured (i.e. falls, motor vehicle crashes with injuries, self-reported injuries, accidents and injuries, injury-related visits to the ED, injuries treated by a doctor, injury-related hospitalizations) precluded meaningful combination.

 

Potential biases in the review process

Publication bias is an important threat to the validity of systematic reviews. Such bias may arise if outcome data are selectively omitted from published reports because the results fail to reach significance. To avoid the effects of this type of bias we wrote to the authors of all identified trials that met our first three inclusion criteria, asking them whether they collected any data on injuries or their antecedents, and to provide such data if available. Nine additional completed trials, long-term follow-up of another completed trial, and one trial still in progress, were identified by this approach. However, we were able to obtain unpublished injury-related data from only four of the completed trials. The difficulties involved in extracting unpublished data and other information for systematic reviews have been reported previously (Roberts 1997). More than half of the authors of studies that met our first three inclusion criteria were deceased or untraceable or did not respond to our requests for information. While it is likely that some did not respond because they did not measure injury outcomes, the inability to identify all unpublished data might have biased our results.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms

 

Implications for practice

Interventions for problem drinking appear to have beneficial effects on injury risk, but this benefit does not necessarily correlate with the effect of the intervention on abstinence, alcohol consumption, or drinking-related hazardous behavior.

 
Implications for research

Previous reviews have shown that interventions for problem drinking can reduce alcohol consumption (Freemantle 1993) and driving under the influence of alcohol (Wells-Parker 1995). This review indicates that interventions for problem drinking are likely to reduce the incidence of injuries and their antecedents, but current data are insufficient to draw firm conclusions, particularly in terms of effects on violent injuries. Because injuries account for a large proportion of the morbidity and mortality due to problem drinking, further studies are warranted to evaluate the effect that treating problem drinking may have on injuries and to investigate how any beneficial effects on injuries are mediated.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms

An earlier version of this review was published as 'Dinh-Zarr T, DiGuiseppi C, Heitman E, Roberts I. Preventing injuries through interventions for problem drinking: a systematic review of randomized controlled trials. Alcohol & Alcoholism 1999; 34: 609-21.' It is reprinted here by permission of the Medical Council on Alcoholism.

We gratefully acknowledge the assistance of Drs Ralph Bloch and Ellen Ingham (translations), Dr Robert Zarr, Darmendra Ramcharran and Adam Howard (data collection), and all the researchers who sent us information and unpublished data.

This research was supported in part by Grant Number R49/CCR811509 from the Centers for Disease Control and Prevention (CDC), US Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms
Download statistical data

 
Comparison 1. Brief intervention for problem drinking vs control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Injury-Related Deaths31555Risk Ratio (M-H, Random, 95% CI)0.65 [0.21, 2.00]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms
 

Appendix 1. Search strategy

MEDLINE (1966 to March 2002)
1. (ALCOHOLIC-INTOXICATION OR ALCOHOL-DRINKING OR ALCOHOLISM OR  TEMPERANCE) in MJME
2. (dr?nk* NEAR3 excess*) or (dr?nk* NEAR3 binge*) or (dr?nk* NEAR3 heavy*) or (dr?nk* NEAR3 hazard*) or (dr?nk* NEAR3 problem*) or (dr?nk* NEAR3 abuse*) or (dr?nk* NEAR3 influence*)
3. (alcohol* NEAR3 excess*) or (alcohol* NEAR3 binge*) or (alcohol* NEAR3 heavy*) or (alcohol* NEAR3 hazard*) or (alcohol* NEAR3 problem*) or (alcohol* NEAR3 abuse*) or (alcohol* NEAR3 influence*)
4. 1 OR 2 OR 3
5. (WOUNDS-AND-INJURIES/prevention and control OR ACCIDENT-PREVENTION) in MJME
6. (injur* OR accident* OR prevent*)
7. (6 in TI) or (6 in AB)
8. 5 OR 7
9. 4 and 8
Aboved combined with the optimally sensitive MEDLINE strategy for RCTs (Dickersin 1994)

EMBASE (1982 to May 2002)
1. ALCOHOL ABUSE OR ALCOHOL INTOXICATION OR ALCOHOL ABSTINENCE
2. (dr#nk$ NEAR3 excess$) or (dr#nk$ NEAR3 binge$) or (dr#nk$ NEAR3 heavy$) or (dr#nk$ NEAR3 hazard$) or (dr#nk$ NEAR3 problem$) or (dr#nk$ NEAR3 abuse$) or (dr#nk$ NEAR3 influence$)
3. (alcohol$ NEAR3 excess$) or (alcohol$ NEAR3 binge$) or (alcohol$ NEAR3 heavy$) or (alcohol$ NEAR3 hazard$) or (alcohol$ NEAR3 problem$) or (alcohol$ NEAR3 abuse$) or (alcohol$ NEAR3 influence$)
4. 1 OR 2 OR 3
5. INJURY/prevention OR ACCIDENT PREVENTION
6. (injur* OR accident* OR prevent*).ti,ab.
7. 5 OR 6
8. RANDOMIZED CONTROLLED TRIAL OR RANDOMIZATION
9. randomi#ed or double blind or single blind
10. 8 or 9
11. 4 and 7 and 10

CENTRAL (The Cochrane Library 2002, Issue 2)
#1 (drink*) near (excess* or binge* or heavy* or hazard* or problem* or abuse* or influence*)
#2 (alcohol*) near (excess* or binge* or heavy* or hazard* or problem* or abuse* or influence*)
#3 (drunk*) near (excess* or binge* or heavy* or hazard* or problem* or abuse* or influence*)
#4 #1 or #2 or #3
#5 injur* or accident* or prevent*
#6 #4 and #5

Transport 1988 to 2002/03
#1. drink*
#2. excess*
#3. binge*
#4. heavy*
#5. hazard*
#6. problem*
#7. abuse*
#8. influence*
#9. (drink*) near (excess* or binge* or heavy* or hazard* or problem* or abuse* or influence*)
#10. alcohol*
#11. alcohol* near (#2 or #3 or #4 or #5 or #6 or #7 or #8)
#12. drunk*
#13. drunk* near (#2 or #3 or #4 or #5 or #6 or #7 or #8)
#14. #9 or #11 or #13
#15. injur*
#16. accident*
#17. prevent*
#18. injur* or accident* or prevent*
#19. (#18 in ti) or (#18 in ab)
#20. trial*
#21. randomi*
#22. controlled
#23. double
#24. blind*
#25. single*
#26. blind*
#27. trial* or randomi* or controlled or double blind* or single blind*
#28 #14 and #19 and #27

PsycINFO (1967 to Feb 2002)
1. ALCOHOL ABUSE OR ALCOHOL INTOXICATION OR ALCOHOLISM OR SOBRIETY
2. (dr?nk* NEAR3 excess*) or (dr?nk* NEAR3 binge*) or (dr?nk* NEAR3 heavy*) or (dr?nk* NEAR3 hazard*) or (dr?nk* NEAR3 problem*) or (dr?nk* NEAR3 abuse*) or (dr?nk* NEAR3 influence*)
3. (alcohol* NEAR3 excess*) or (alcohol* NEAR3 binge*) or (alcohol* NEAR3 heavy*) or (alcohol* NEAR3 hazard*) or (alcohol* NEAR3 problem*) or (alcohol* NEAR3 abuse*) or (alcohol* NEAR3 influence*)
4. 1 OR 2 OR 3
5. INJURIES or ACCIDENT PREVENTION
6. (injur* OR accident* OR prevent*)
7. (6 in TI) or (6 in AB)
8. 5 OR 7
9. (clinical-trial in pt)
10. (randomi* or double blind or single blind)
11. 9 OR 10
12. 4 AND 8 AND 11

ERIC (1966 to12/1996)

  1. ALCOHOL ABUSE
  2. ALCOHOLISM
  3. 1 or 2
  4. INJURIES
  5. ACCIDENT PREVENTION
  6. 4 or 5
  7. 3 and 6

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms

Last assessed as up-to-date: 31 March 2004.


DateEventDescription

9 June 2008AmendedConverted to new review format.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms

Protocol first published: Issue 4, 1999
Review first published: Issue 4, 1999


DateEventDescription

1 April 2004New search has been performedSubstantive amendment.

An electronic search for new trials was performed in May 2002. In May 2004 progress was updated for trials which had been ongoing during the original review. Search strategies identified six eligible completed trials, and reviewers amended all applicable sections to incorporate results from these six trials.

New data from Ojehagen et al 1997 have been added.

1 May 2002New search has been performedNew studies found but not yet included or excluded.



 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Declarations of interest
  14. Sources of support
  15. Index terms
 

Internal sources

  • No sources of support supplied

 

External sources

  • Camden and Islington Health Authority (DiGuiseppi), UK.
  • University of Texas-Houston Health Science Center Summer Internship (Dinh-Zarr), USA.
  • Centers for Disease Control and Prevention (Grant #R49/CCR811509), USA.
  • AAA National Office, Washington, DC, USA.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Declarations of interest
  15. Sources of support
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
  21. References to other published versions of this review
Barber 1995 {published and unpublished data}
Brown 1980 {published and unpublished data}
Fitzgerald 1985 {published and unpublished data}
Fleming 1999 {published data only}
  • Fleming MF, Manwell LB, Barry KL, et al. Brief physician advice for alcohol problems in older adults: A randomized community-based trial. Journal of Family Practice 1999;48:378-84.
Fleming 2002 {published data only}
Gallant 1968 {published and unpublished data}
  • Gallant DM, Bishop MP, Camp E, Tisdale C. A six-month controlled evaluation of metronidazole (Flagyl) in chronic alcoholic patients. Current Therapeutic Research 1968;10(2):82-7.
Gentilello 1999 {published data only}
Kristenson 2002 {published data only}
Kuchipudi 1990 {published and unpublished data}
  • Kuchipudi V, Hobein K, Flickinger A, Iber FL. Failure of a 2-hour motivational intervention to alter recurrent drinking behaviour in alcoholics with gastrointestinal disease. Journal of Studies on Alcohol 1991;51:356-60.
Landrum 1981 {published data only}
  • Landrum J, Miles S, Neff R, et al. Mississippi DUI Follow-up Project. National Highway Traffic Safety Administration. Washington, DC, 1981; Vol. Final report. [: DOT-HS-806 274]
Longabaugh 2001 {published data only}
  • Longabaugh R, Woolard RF, Nirenberg TD, et al. Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department. Journal of Studies on Alcohol 2001;62:806-16.
Mann 1994 {published data only}
  • Mann RE, Anglin L, Wilkins K, et al. Rehabilitation for convicted drinking drivers (second offenders): effects on mortality. Journal of Studies on Alcohol 1994;55:372-4.
Monti 1999 {published data only}
  • Monti PM, Colby SM, Barnett NP, et al. Brief interventions for harm reduction with alcohol-positive older adolescents in a hospital emergency department. Journal of Consulting and Clinical Psychology 1999;67:989-94.
Potamianos 1986 {published data only}
  • Potamianos G. A randomised controlled trial of a community-based centre in the treatment of alcoholism [PhD dissertation]. 1986.
  • Potamianos G, North WRS, Meade TW, Townsend J, Peters TJ. Randomised trial of community-based centre versus conventional hospital management in treatment of alcoholism. Lancet 1986;October 4:797-9.
Reis 1982a {published and unpublished data}
  • Reis RE, Davis LA. First interim analysis of first offender treatment effectiveness. National Highway Traffic Safety Administration, 1981. [: Report Number: CDUI-IE-80-1Intrm Rpt.; Report Number: HS-805 577]
Reis 1982b {published and unpublished data}
  • Reis RE. Analysis of traffic safety impact of educational counseling programs for multiple offense drunk drivers. Vol. 1980 annual report: volume V, National Highway Traffic Safety Administration, 1982. [: Report Number : CDUI-AN-5-80 Intrm Rpt.; Report Number: HS-806 555]
Sitharthan 1996 {published and unpublished data}
Sitharthan 1997 {published data only}
  • Sitharthan T, Sitharthan G, Hough M, Kavanaugh DJ. Cue exposure in moderation drinking: a comparison with cognitive-behavior therapy a comparison with cognitive-behavior therapy. Journal of Consulting and Clinical Psychology 1997;65:878-82.
Toteva 1996 {published and unpublished data}
  • Toteva S, Milanov I. The use of body acupuncture for treatment of alcohol dependence withdrawal syndrome: a controlled study. American Journal of Acupuncture 1996;24:19-25.
Walsh 1991 {published data only}
WHO BISG 1996 {published data only}
  • WHO Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. American Journal of Public Health 1996;86:948-55.
Öjehagen 1997 {published and unpublished data}
  • Öjehagen A, Berglund M, Appel CP. Long-term outpatient treatment in alcoholics with previous suicidal behavior. Suicide & Life Threatening Behavior 1993;23:320-8.
  • Öjehagen A, Schaar I, Berglund M. Nine-year follow-up of outpatient psychiatric- versus multimodal behavioural therapy in alcoholics, a randomised study. (Poster Presentation). 6th Congress European Society for Biomedical Research on Alcoholism. Stockholm.. 1997.

References to studies excluded from this review

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Declarations of interest
  15. Sources of support
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
  21. References to other published versions of this review
Anderson 1992 {published data only}
McCrady et al 1982 {published and unpublished data}
  • McCardy BS, Moreau J, Paolino TJ, Longabaugh R. Joint hospitalization and couples therapy for alcoholism: a four-year follow-up. Journal of Studies on Alcohol 1982;43:1244-50.
Wells-Parker 2002 {published and unpublished data}
  • Wells-Parker E, Williams M. Enhancing the effectiveness of traditional interventions with drinking drivers by adding brief individual intervention components.. Journal of Studies on Alcohol 2002;63:655-64.

Additional references

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Declarations of interest
  15. Sources of support
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
  21. References to other published versions of this review
Andreasson 1988
Babor 1994
  • Babor TF, Longabaugh R, Zweben A, et al. Issues in the definition and measurement of drinking outcomes in alcoholism treatment research. Journal of Studies on Alcohol Supplements 1994;12:101-11.
Bailar 1997
Cunradi 2002
Dickersin 1994
DSM-IV-TR 2000
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. IV. Washington, DC: American Psychiatric Association, 2000.
Freemantle 1993
  • Freemantle N, Gill P, Godfrey C, et al. Brief interventions and alcohol use. Effective Health Care 1993;Bulletin Number 7. University of Leeds, Leeds, United Kingdom.
Hungerford 2003
IOM 1990
  • Institute of Medicine, Division of Mental Health and Behavioural Medicine. Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press, 1990.
Lancet 1997
  • The Lancet. Meta-analysis under scrutiny [editorial]. Lancet 1997;350:675.
McDonald 2004
  • McDonald AJ III, Wang N, Camargo C Jr. US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. Archives of Internal Medicine 2004;164:531-7.
NCIPC 2001
  • National Committee for Injury Prevention and Control. Injury fact book: 2001-2002. Atlanta: Centers for Disease Control and Prevention, 2001.
O'Farrell 1995
Rehm 2003
Roberts 1997
Schulz 1995
  • Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias: dimensions of methodological quality associated with the estimates of treatment effects in controlled trials. Journal of the American Medical Association 1995;273:408-12.
USPSTF 1996
  • US Preventive Services Task Force. Screening for problem drinking. In: DiGuiseppi C, Atkins D, Woolf S, Kamerow D editor(s). Guide to Clinical Preventive Services. 2nd Edition. Washington, DC: US General Printing Office, 1996:567-82.
Vinson 1995
  • Vinson DC, Mabe N, Leonard LL, et al. Alcohol and injury. A case-crossover study. Archives of Family Medicine 1995;4:505-11.
Wells-Parker 1995