Interventions for preventing injuries in problem drinkers

Authors


Abstract

Background

Alcohol consumption has been linked with injuries through motor vehicle crashes, falls, drowning, fires and burns, and violence. In the US, half of the estimated one hundred thousand deaths attributed to alcohol each year are due to intentional and unintentional injuries. The identification of effective interventions for the reduction of unintentional and intentional injuries due to problem drinking, is therefore an important public health goal.

Objectives

To assess the effect of interventions for problem drinking on subsequent injury risk.

Search strategy

Data Sources.- Twelve computerized databases: MEDLINE (1966-8/96), EMBASE (1982-1/97), Cochrane Controlled Trials Register (1997, issue #1), PSYCHINFO (1967-1/97), CINAHL (1982-10/96), ERIC (1966-12/96), Dissertation Abstracts International (1861-11/96), IBSS (1961-1/97), ISTP (1982-1/97) and three specialized transportation databases, using terms for problem drinking combined with terms for controlled trials; bibliographies of relevant trials; and contact with authors and government agencies.

Selection criteria

Data Selection.- Randomized controlled trials of interventions among particiapnts with problem drinking, which are intended to reduce alcohol consumption or to prevent injuries or their antecedents, and which measured injury-related outcomes. Of 7014 studies identified, 19 (0.3%) met the inclusion criteria.

Data collection and analysis

Data Extraction.- Two authors extracted data on participants, interventions, follow-up, allocation concealment, and outcomes, and independently rated allocation concealment quality.

Main results

Data Synthesis.- In completed trials, interventions for problem drinking were associated with reduced suicide attempts, domestic violence, falls, drinking-related injuries, and injury hospitalizations and deaths, with reductions ranging from 27-65%. Several interventions among convicted drunk drivers reduced motor vehicle crashes and injuries. Because few trials were sufficiently large to assess effects on injuries, individual effect estimates were imprecise. We did not combine the results quantitatively because the interventions, patient populations, and outcomes were so diverse.

Reviewers' conclusions

Conclusion.- Interventions for problem drinking may reduce injuries and their antecedents. Because injuries account for much of the morbidity and mortality from problem drinking, further studies are warranted to evaluate the effect of treating problem drinking on injuries.

Plain language summary

Synopsis

To be added.

Background

Alcohol consumption has been linked with injuries incurred through motor vehicle crashes, falls, drowning, fires and burns, and violence (NCIPC 1989, USPTF 1996). Compared to the general population, alcoholics have a sixteen times greater risk of dying by falling and a ten times greater risk of dying by fire or burns (NCIPC 1989). A strong association has been found between alcoholism and domestic violence (O'Farrell 1995). Even moderate alcohol consumption has been associated with increases in deaths from trauma (Andreasson 1988). 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, half of the estimated one hundred thousand deaths attributed to alcohol each year are due to intentional and unintentional injuries (Stinson 1992). Based on estimates of global injury mortality and its contributors (Murray 1997a, Murray 1997b), alcohol-related injuries world-wide may cause several million deaths each year.

Numerous randomised controlled trials have evaluated a diverse range of interventions to reduce alcohol dependence, abuse or consumption: pharmacotherapy; individual, couple, and group counselling; 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., hospitalisations, social or occupational maladjustment) (Babor et al 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

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

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 (DSMV IV 1994). 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 (DSMV IV 1994). Hazardous use of alcohol, such as binge or chronic heavy drinking, places asymptomatic drinkers at risk for future health and other problems (USPTF 1996). For the purposes of this review, we refer to alcohol dependence, alcohol abuse, and hazardous use of alcohol as "problem drinking."

Types of intervention

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 strategy for identification of studies

See: Unavailable search strategy

Data Sources

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.

Twelve electronic databases were searched: MEDLINE (1966-August 1996), EMBASE (1982-January 1997), the Cochrane Controlled Trials Register (The Cochrane Library 1997, issue #1), PSYCHINFO (1967- January 1997), the Cumulative Index to Nursing and Allied Health (CINAHL) (1982-October 1996), the Educational Resource Information Center (ERIC) (1966- December 1996), Dissertation Abstracts International (1861-November 1996), International Road Research Documentation (IRRD) (1972-January 1997), TRANSDOC (a publication of the European Conference of Ministers of Transport) (1972-January 1997), Transportation Research Information Service (TRIS) (1968-January 1997), the International Bibliography of the Social Sciences (IBSS) (1961-January 1997), and the Index of Scientific & Technical Proceedings (ISTP) (1982-January 1997).

MEDLINE was searched by combining the Cochrane Collaboration's optimally sensitive search strategy for controlled trials (Dickersin 1994) with a strategy developed to identify studies of interventions for problem drinking. Search terms included the mesh headings (explode) ALCOHOLIC-INTOXICATION, (explode) ALCOHOLISM, ALCOHOL-DRINKING, and TEMPERANCE, with all subheadings; and text terms including: drink* or alcohol* near excessive, binge, heavy, hazard*, problem* or abuse; drink* or drunk* or influence near driv*; (accidents-traffic or automobile-driving) and alcohol*; and alcoholi*. Similar search strategies were developed for the other databases. We also hand-searched 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), and Väg-och Trafik-Institutet (Sweden).

Methods of the review

Study Selection

One author (T.D.) 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

Two reviewers (T.D., C.D.) 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; 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.

Description of studies

Of the 7014 published and unpublished studies identified by our search strategies, 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 and Scott 1992, Ojehagen 1993, Mann et al 1994, Barber and Crisp 1995, Sitharthan et al 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 9 eligible completed studies (Gallant et al 1968, Landrum et al 1981, McCrady et al 1982, Fitzgerald and Mulford 1985, Potamianos et al 1986, Kuchipudi et al 1990, WHO 1996, Toteva and Milanov 1996, Sitharthan et al 1997). We also identified three eligible trials in progress and one study in progress assessing long-term follow-up of a previously published trial (See List of On-going Studies). Two trials (McCrady et al 1982, Anderson and Scott 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. Thus, we identified a total of 19 randomized controlled trials that met all four inclusion criteria (See Table of Included Studies and List of On-going Studies). 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 and Crisp 1995, Gallant et al 1968, Fitzgerald and Mulford 1985, Kuchipudi et al 1990).

Methodological quality

Four completed trials received an 'A' rating for allocation concealment (Reis 1982a, Reis 1982b, Fitzgerald and Mulford 1985, Potamianos et al 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 (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 effect on their effect estimates regardless of whether these subjects were included or excluded from the control group (personal communication, HA Mulford, September 1997).

Results

Due to the diversity of interventions, patient populations, and types of injury outcomes reported, no attempt was made to combine the results quantitatively. Effects of intervention on abstinence and alcohol consumption are shown in the Notes section of the Table of Included Studies.

Mortality

Six completed trials collected injury mortality outcomes. Twenty-one total deaths were reported in the five trials for which data were available (Gallant 1968, Kuchipudi 1990, Mann 1994, Ojehagen 1993, Walsh 1991). The two trials comparing intervention to no intervention both reported a reduced risk of death in the intervention group compared to the control group, although both effect estimates were imprecise. Mann 1994 reported 3/220 accidental and violent deaths in the experimental group and 5/127 in the control group (RR=0.35; 95% CI 0.08, 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, 1.43). Surprisingly, Kuchipudi 1990 also reported slightly lower abstinence rates and higher rates of driving under the influence of alcohol (DUI) in the intervention group (see Table of Included Studies). However, these effect estimates were also imprecise.

The other three completed trials reporting injury mortality data compared different treatment modalities, without any 'no intervention' control group. There were too few deaths in each of these three trials (0 in Gallant 1968, 2 in Walsh 1991, 3 in Ojehagen 1993) to identify differences in the effects of specific treatment modalities on injury deaths. Toteva and Milanov 1996 reported collecting data on suicides, but these were unavailable.

Non-Fatal Injuries and Their Antecedents

Thirteen completed trials collected data on non-fatal injuries and their antecedents. The results from trials collecting non-fatal injury outcomes specifically identified as related to violence or motor vehicle crashes are summarised separately below. Seven trials collected non-fatal injury outcomes that combined injuries due to a variety of causes. Outcome data were available from only two of these trials, however. In both of these trials, the intervention for problem drinking reduced the risk of injuries or accidents compared to no intervention, despite the fact that neither trial reported beneficial effects of treatment on abstinence. Again, effect estimates were imprecise. Kuchipudi (1990) reported the effect of a motivational intervention on injury-related hospitalisations (2/59 vs 3/55; RR=0.62; 95% CI: 0.11, 3.58) and on falls (3/59 vs 4/55; RR=0.70; 95% CI 0.16, 2.98). Fitzgerald and Mulford (1985) assessed the more specific outcome of drinking-related injuries and accidents, with similar effect when the results from the two centers were pooled: 9/125 vs 17/167; RR=0.73 (95% CI: 0.34, 1.58). Other trials measured the effect of the experimental intervention on accidents (Brown 1980, Walsh 1991, Potamianos 1986) or injuries (WHO BISG 1996), but we were unable to obtain these data.

Non-Fatal Violence

Six completed trials collected data on non-fatal violence, but data were available for only three completed trials. The two trials evaluating intervention versus no intervention both suggested a reduction in violence with intervention (Barber and Crisp 1995, Fitzgerald and Mulford 1985), though only Barber and Crisp (1995) showed any beneficial effect on drink-related outcomes. Barber and Crisp (1995) reported a reduction in 'domestic violence' using the "Pressure to Change" approach for partners of heavy drinkers (4/16 vs 3/7; RR=0.58; 95% CI 0.17, 1.95). Fitzgerald and Mulford (1985) reported a reduction in suicide attempts with telephone aftercare contacts (4/125 vs 11/167; RR=0.48; 95% CI 0.15, 1.51). The third trial with data available (Sitharthan 1997) compared two different interventions and 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 (1997) found a greater reduction in alcohol consumption with cue exposure therapy, however.

Other 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.

Motor Vehicle Crashes

Four completed trials assessed the effect of intervention on motor vehicle crashes and on injuries following motor vehicle crashes. Data were available from three 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 (0.51, 1.13); RR=0.85 (0.57, 1.26); and RR=0.90 (0.60, 1.35), respectively. Monthly probation and structured rehabilitation had stronger effects on motor vehicle crash injuries (RR=0.47; 95% CI 0.20, 1.11 and RR=0.58; 95% CI 0.26, 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, 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 .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 counselling 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 counselling alone (0.087) than in controls, despite the fact that counselling alone was as effective as counseling with disulfiram in reducing DUI arrest recidivism.

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

Discussion

Injury is a major public health problem world-wide 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 suggest that interventions for problem drinking may be effective in reducing injuries and injury deaths. In the seven 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 large, ranging from a 27% reduction of 'drinking-related injuries and accidents' to a 65% reduction in 'accidental and violent deaths'. Because the trial sample sizes were generally small, however (few of the trials having been designed to measure effects on injuries), the precision of these estimates was low. Nevertheless, these results suggest that interventions to reduce problem drinking could have an important effect on the incidence of injuries and 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, Reis (1982a) and Barber (1995) found a beneficial effect of intervention on drink-related outcomes, while Fitzgerald (1985) and Kuchipudi (1990) showed slight adverse effects. Similarly, Reis (1982a, 1982b) found significant reductions in DUI recidivism rates in both of his trials, but Landrum (1981) reported only a slight reduction in DUI incidence with intervention and Kuchipudi (1990) found an increase in DUI rates. In two of four completed trials that compared different treatment modalities and provided data on injury outcomes, there were significantly greater declines in alcohol consumptions with one therapeutic modality compared to the other(s) (Walsh 1991, Sitharthan 1997). 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 any beneficial effect on injuries is mediated by other aspects of treatment for problem drinking (e.g., receipt of medical attention and social support).

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 et al 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 totality of the randomised 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, this would have involved combining markedly heterogeneous groups of participatants, interventions, and outcomes. In such circumstances, a meta-analysis can produce inappropriate, and even misleading, conclusions (Bailar 1997, The Lancet 1997).

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 if they collected any data on injuries or their antecedents, and to provide such data if available. Nine additional completed trials, three trials still in progress, and long-term follow-up of another completed trial in progress, were identified by this approach. However, we were able to obtain the 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 and Schierhout 1997). Many of the authors of studies that met our first three inclusion criteria were deceased or untraceable (7%) or did not respond to our requests for information (55%). 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.

Reviewers' conclusions

Implications for practice

Interventions for problem drinking may have beneficial effects on injury risk, and this benefit does not necessarily correlate with the effect of the intervention on the abstinence or on alcohol consumption.

Implications for research

Previous reviews have shown that interventions for problem drinking can reduce alcohol consumption (Freemantle et al 1993) and driving under the influence of alcohol (Wells-Parker et al 1995). This review suggests that interventions for problem drinking have the potential to reduce the incidence of injuries and their antecedents, but current data are insufficient to draw firm conclusions. 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.

Potential conflict of interest

None known.

Acknowledgements

This review has been 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 (data collection), and all the researchers who sent us information and unpublished data.

Characteristics of included studies

Study Barber 1995
Methodsrandomized controlled trial
Participants23 partners of heavy drinkers (22 women, 1 man)
Interventions1) training partners to pressure heavy drinkers to change
2) no intervention
OutcomesDomestic violence:
1) 4/16 (25%)
2) 3/7 (43%)
RR=0.58 (95% CI 0.17, 1.95); p=0.63
NotesAustralia. 3 month follow-up.

N and % fully abstinent:
1) 1/16 (6%)
2) 0/7 (0%)

% subjects taking <4 drinks (10 g etoh) per day:
1) 3/16 (19%)
2) 0/7 (0%)
Allocation concealmentB
Study Brown 1980
Methodsrandomized controlled trial
Participants60 males convicted of DUI
Interventions1) conventional education
2) controlled drinking
3) no intervention
OutcomesAccidents
Data unavailable
NotesNew Zealand. 12 month follow-up

Mean days abstinent/90 days:
1) 48.0
2) 58.4
3) 53.6

Average DUI incidence/year:
1) 32.40
2) 7.25
3) 23.95
Allocation concealmentB
Study Fitzgerald 1985
Methodsrandomized controlled trial
Participants288 alcoholics (from 2 centers A & B)
Interventions1) telephone aftercare contacts
2) no or minimal aftercare intervention
OutcomesDrinking-related injuries and accidents
1) A: 7/86, B: 2/39 (7%)
2) A: 14/127, B: 3/40 (10%)
RR*=0.73 (95% CI 0.34, 1.58); p=0.55

Suicide attempts:
1) A; 2/86; B: 2/39 (3%)
2) A: 9/127; B: 2/40 (7%)
RR*=0.48 (95% CI 0.15, 1.51); p=0.31
*Mantel-Haenzel weighted relative risk, stratified by Center.
NotesUSA. 12 months follow-up

N and % fully abstinent
1) 26/123 (21%)
2) 37/165 (22%)
Allocation concealmentA
Study Gallant 1968
Methodsrandomized controlled trial
Participants78 male alcoholics
Interventions1) metronidazole (125 mg qid)
2) chlordiazepoxide (10 mg qid)
OutcomesSuicides
1) 0/39
2) 0/39
Relative Risk undefined.
NotesUSA. 6 month follow-up

N and % fully abstinent
1) 6/39 (15%)
2) 8/39 (21%)
Allocation concealmentB
Study Kuchipudi 1990
Methodsrandomized controlled trial
Participants114 alcoholics hospitalised for medical illness
Interventions1) motivational intervention and medical care
2) medical care only
OutcomesSuicides and violent deaths:
1) 3/59 (5%)
2) 5/55 (9%)
RR=0.56 (95% CI 0.08, 1.43); p=0.48

Injury hospitalisations:
1) 2/59 (3%)
2) 3/55 (5%)
RR=0.62 (95% CI 0.11, 3.58); p=0.67

Falls:
1) 3/59 (5%)
2) 4/55 (7%)
RR=0.70 (95% CI 0.16, 2.98); p=0.71
NotesUSA. 10-16 wk followup

N and % fully abstinent:
1) 21/59 (36%)
2) 20/55 (36%)

N and % Driving Under The Influence:
1) 8/59 (14%)
2) 5/55 (9%)
Allocation concealmentB
Study Landrum 1981
Methodsrandomized controlled trial
Participants3425 persons convicted of DUI
Interventions1) monthly probation
2) rehabilitation (group therapy/ structured intervention)
3) probation & rehabilitation
4) no intervention
OutcomesMotor vehicle crashes
1) 41/552 (7%)
2) 42/504 (8%)
3) 38/431 (9%)
4) 48/490 (10%)
RR (95% CI); p-value
1) 0.76 (0.51, 1.13); p=0.21
2) 0.85 (0.57, 1.26); p=0.49
3) 0.90 ( 0.60, 1.35); p=0.69
4) 1.0

Motor vehicle crash injuries
1) 8/552 (1%)
2) 9/504 (2%)
3) 14/431 (3%)
4) 15/490 (3%)
RR (95% CI); p-value
1) 0.47 (0.20, 1.11); p=0.12
2) 0.58 (0.26, 1.32); p=0.27
3) 1.06 (0.52, 2.17); p=0.98
4) 1.0
NotesUSA. 24 month follow-up

DUI Repeat Arrestees
1) 179/552 (32%)
2) 168/504 (33%)
3) 132/431 (31%)
4) 162/490 (33%)
Allocation concealmentB
Study Mann 1994
Methodsrandomized controlled trial
Participants347 men twice convicted of DUI
Interventions1) rehabilitation program
2) no program
OutcomesAccidental and violent deaths:
1) 3/220 (1%)
2) 5/127 (4%)
RR=0.35 (95% CI 0.08, 1.43); p=0.15
NotesCanada. Followup 8-13 yr.
Allocation concealmentB
Study Ojehagen 1993
Methodsrandomized controlled trial
Participants72 alcoholics
Interventions1) psychiatric outpatient treatment - 1 yr
2) psychiatric outpatient treatment - 2 yr
3) multi-modal behavioural outpatient treatment -1 yr
4) multi-modal behavioural outpatient treatment - 2 yr
OutcomesSuicides:
1+2) 2/36 (6%)
3+4) 1/36 (3%)
RR=2.0 (95% CI 0.19, 21.09); p=1.00
NotesSweden. Followup 36 mo (9-12 year follow-up in progress)

% subjects taking >4 drinks (3.8 cl 40% etoh) per day on 14 or fewer days/yr:
1) 44%
2) 40%
3) 41%
4) 42%
Allocation concealmentB
Study Potamianos 1986
Methodsrandomized controlled trial
Participants151 problem drinkers aged 18-60
Interventions1) community-based day center treatment
2) conventional in- and out-patient management
OutcomesAccidents
Aggressive behavior
Motor vehicle crashes
(Data Unavailable)
NotesUK. 12 months follow-up

Mean alcohol consumption:
1) 89 g/d (55% reduction)
2) 106 g/d (37% reduction)
Allocation concealmentA
Study Reis 1982a
Methodsrandomized controlled trial
Participants4639 persons once convicted of DUI
Interventions1) in-class education
2) home study education
3) no intervention
OutcomesAlcohol-related crashes & injuries ('Cumulative accident rate')
) 0.084
2) 0.098
3) 0.101
Overall: p=0.58
NotesUSA. 3 yr follow-up

Mean change in drinking score:
1) -12.40
2) -18.53
3) -16.36

DUI recidivism rate
1) 0.24
2) 0.25
3) 0.28
Allocation concealmentA
Study Reis 1982b
Methodsrandomized controlled trial
Participants1103 persons convicted more than once of DUI
Interventions1) biweekly contacts (BWC)
2) educational counselling
3) educational counselling with disulfiram
3) no intervention
OutcomesAlcohol-related crashes & injuries ('Cumulative accident rate')
1) 0.086
2) 0.087
3) 0.055
4) 0.076
Overall: p=0.49
NotesUSA. 2 year follow-up

Mean change in drinking score:
1) -49.53
2) -40.91
3) -72.87
4) -16.73

DUI recidivism rate
1) 0.25
2) 0.23
3) 0.21
4) 0.29
Allocation concealmentA
Study Sitharthan 1996
Methodsrandomized controlled trial
Participants121 'low-dependent' problem drinkers compliant with therapy
Interventions1) cognitive behavioural therapy by correspondence
2) minimum intervention by correspondence
OutcomesAssaults
Data unavailable
NotesAustralia. 4 month follow up

Mean alcohol consumption:
Men
1) 24.7 ±16.8 g/wk
2) 37.2 ± 24.4 g/wk
Women:
1) 16.4 ±10.5 g/wk
2) 23.7 ±10.3 g/wk
Allocation concealmentB
Study Sitharthan 1997
Methodsrandomized controlled trial
Participants52 problem drinkers
Interventions1) cue exposure therapy
2) cognitive behavioural therapy
OutcomesAssaults
1) 5/27 (19%)
2) 0/25 (0%)
RR=infinity (95% CI 0.91, infinity); p=0.06
(Confidence interval based on odds ratio approximation.)
NotesAustralia. 12 month follow up

Days/month when any drink taken:
1) 6.23 d/mo
2) 11.93 d/mo
Allocation concealmentB
Study Toteva 1996
Methodsrandomized controlled trial
Participants118 alcoholics
Interventions1) acupuncture
2) medical detoxification
OutcomesSuicides
Data unavailable
NotesBulgaria. Followup 6 months

N and % fully abstinent ('Total remission rate')
1) 11/15 (73%)
2) 10/21 (48%)
Allocation concealmentB
Study WHO BISG, 1996
Methodsrandomized controlled trial
Participants1559 heavy drinkers in ten countries
Interventions1) simple advice
2) brief counselling
3) no intervention
OutcomesInjuries
Data unavailable
Notes10 Countries. 9 month follow up

N and % fully abstinent:
Men
1) 19/387 (5%)
2) 38/471 (8%)
3) 8/403 (2%)
Women
1) 8/109 (7%)
2) 13/105 (12%)
3) 3/83 (4%)

Mean alcohol consumption:
Men
1) 5.18 cl ETOH/d
2) 5.29 cl ETOH/d
3) 6.29 cl ETOH/d
Women
1) 3.39 cl ETOH/d
2) 2.99 cl ETOH/d
3) 3.80 cl ETOH/d
Allocation concealmentB
Study Walsh 1991
Methodsrandomized controlled trial
Participants227 alcohol-abusing workers
Interventions1) compulsory inpatient treatment
2) compulsory Alcoholics Anonymous attendance
3) choice of optional treatment
OutcomesSuicides and homicides:
1) 2/73 (3%)
2) 0/83 (0%)
3) 0/71 (0%)
RR (95% CI); p-value
1) infinity (0.18, infinity)*; p=0.51
2) undefined
3) 1.0
*confidence interval based on odds ratio approximation.

Accidents: Data unavailable
NotesUSA. 2 yr followup

N and % Fully Abstinent
1) 27/73 (37%)
2) 13/83 (16%)
3) 12/71 (17%)
Allocation concealmentB

Characteristics of excluded studies

StudyReason for exclusion
Anderson 1992The 'injury' outcome measure was found to include alcohol-related illness; the data on injuries could not be separated from the illness data.
McCrady et al 1982The 'injury' outcome measures were found to include criminal behaviour. These data did not differentiate between criminal behaviour related to injury (e.g., assault) and other types of criminal behaviour (e.g., shop lifting), nor could the injury-specific data be extracted.

Graphs

This review has no graphs.

Sources of support

External sources of support

  • Camden and Islington Health Authority (DiGuiseppi) UK

  • University of Texas-Houston Health Science Center Summer Internship (Dinh-Zarr) USA

Internal sources of support

  • No sources of support supplied

Ancillary