Evidence of effectiveness of community pharmacy-based services for alcohol misuse
Three feasibility studies were identified that evaluated the effect of screening and brief interventions as community pharmacy-based services for the management of excess alcohol consumption, all of which were conducted in the UK6,8,9 (Table 46–9,13).
Table 4. Comparison of three community pharmacist-based alcohol-screening and brief intervention studies
| ||Dhital 20047,8||Fitzgerald 20066,13||Goodall 20069|
|Location of study||London||Glasgow||Leeds|
|Duration of education programme||2 days||2 days||Unspecified|
|Duration of study (months)||3||4||3|
|Pharmacists recruited/trained (n)||1||8||5|
|Counter staff recruited/trained (n)||0||13||Total not specified|
|Clients recruited (n)||73||70||352|
|Clients approached||Not reported||Not reported||Not reported|
|Clients followed-up, n (%)||40 (55%)||19 (27%)||Not specified|
|Clients identified as harmful or hazardous drinkers, n (%)||26 (36%)||37 (53%)||105 (30%; all hazardous)|
|Duration of follow-up (months)||3||4||3|
|Screening tool used||AUDIT||FAST||FAST|
|Research design||Uncontrolled, before-and- after study||Uncontrolled, before-and- after study||Uncontrolled, before-and- after study|
The study by Dhital was conducted in London in 2004 in a single community pharmacy.8 One-third of people screened by the pharmacist were categorised as harmful or hazardous drinkers. The pharmacist intervention included increasing client awareness about alcohol, assessing current drinking behaviour, conducting screening with a validated tool and providing a brief intervention based upon the results. Training was provided for the pharmacist prior to their involvement in the study. Non-significant reductions in alcohol consumption were reported by customers who received a brief intervention. This was a small-scale, uncontrolled study in one pharmacy (n = 73 customers recruited). No sample size calculation was presented.
A feasibility study was conducted in 2005 by Fitzgerald and Stewart.6 Self-selected pharmacists from eight pharmacies in one geographical area participated. The pharmacists' training included information sessions describing screening and brief interventions and exploration of their attitudes towards alcohol. The training methods included roleplay, group discussion and question-and-answer sessions. Of the 70 customers who participated, 10% and 43% were categorised as harmful drinkers and hazardous drinkers, respectively. Non-hazardous/non-harmful drinkers (n = 29) had shorter consultations on average (9 min) compared with hazardous/harmful drinkers (n = 30) (12 min) and harmful drinkers (n = 7) (16 min).13 Non-significant reductions in alcohol consumption were demonstrated. No sample-size calculation was presented.
Pharmacists' attitudes and knowledge were also explored during this study. Whereas pharmacists reported no problems with aggressive patients, some suggested that this could have been due to the types of customers who they approached for the intervention (i.e. the pharmacists may have been less likely to approach clients perceived to be more likely to give a negative response). A barrier to the delivery of this service was workload and a facilitator to the recruitment of clients was the use of posters to advertise the service. Some pharmacists reported targeting specific patient populations, for example clients accessing smoking-cessation services, and this targeted approach may explain why this study achieved the highest percentage of hazardous/harmful drinkers of all the studies included in this review.
The third study was conducted in 2006 in Leeds, England and involved six community pharmacies.9 The study assessed whether pharmacists could opportunistically identify patients who were hazardous drinkers. The pharmacists' training included attendance at tutorials about the effect of excessive alcohol on health, the use of the FAST questionnaire and the delivery of brief interventions. Regular meetings were held to discuss the progress of the study, identify barriers and share experiences. One of the six pharmacists withdrew prior to patient recruitment. One of the five remaining pharmacists recruited 83% of all patients and achieved this by adopting various strategies to enhance his recruitment rate. The pharmacists in the four remaining pharmacies reported difficulties with workload, embarrassment and time constraints. Factors that were associated with the high recruitment rate in the fifth pharmacy included the involvement of counter staff (who were trained) to perform the screening test, using specific times of day when the pharmacist was more likely to be available during which the staff would actively screen and providing staff with incentives to recruit customers.
An additional finding of this study was 80% of participants reported being concerned about a friend or colleague's drinking behaviour. No sample-size calculation was presented. The four ‘low-recruitment’ pharmacists reported that the intervention was well accepted by patients, and that with greater resources they would have been able to deliver the service as planned. The pharmacists also suggested that knowing their patients enabled them to deliver the service. The participants also recommended raising the subject of alcohol during consultations for other purposes, for example during medicine reviews.
The three community pharmacy-based studies reviewed above had small sample sizes (in terms of participating pharmacies), all of them were uncontrolled, and none reported customer attitudes towards the interventions. Considerable loss to follow-up of client participants occurred with two studies,6,8 and is a problem reported with other studies that have targeted excess alcohol consumption in primary care.14
Additional information was derived from three studies which examined community pharmacists' attitudes towards providing services relating to excess alcohol consumption. A postal survey was conducted by Kotecki, with a random sample of community pharmacists in the USA who sold alcohol from their premises.15 The response rate was 74.4% (n = 476). Less than one-quarter (23%) of respondents reported that they inquired about their patients' alcohol consumption. Respondents reported being more likely to engage in discussions about alcohol with their patients if they (the pharmacists) believed alcohol to be an ‘important cause of morbidity’.
A survey of 101 randomly selected community pharmacists was conducted in a region of France.16 The purpose of the survey was to explore the pharmacists' attitudes towards the use of alcohol and alcohol-related problems. No response rate was presented. Although it was reported that the respondents' perceived that they had an important role in the prevention of excess alcohol consumption they stated that initiating discussions with patients about this subject was difficult. These results, combined with those from Kotecki's survey, suggest that attitudinal barriers among some community pharmacists reduce the likelihood of them initiating discussions with their customers about alcohol.
A survey of community pharmacists' attitudes towards and knowledge of excess alcohol consumption conducted in New Zealand achieved a response rate of 39%.17 Whereas knowledge of alcohol content of drinks and recommended safe drinking limits was poor, the pharmacists' responses indicated that they were well-motivated towards undertaking a role to address excess alcohol consumption but that they lacked skills and confidence.
Three local primary care organisations in the UK were identified as having undertaken work on the management of excess alcohol consumption as part of community pharmacy public health campaigns. One campaign in Hull, England, focused on the use of drugs and alcohol (V. Fryer, personal communication). Pharmacies were given resources to promote issues associated with drugs and alcohol and to assist in the provision of advice to patients. A training evening was also held during which the primary care trust worked in partnership with colleagues from Hull City Safe to talk about the impact of drugs and alcohol in the local area. It was reported that the pharmacy staff enjoyed the interactive session especially as it did not focus solely on specific drugs or types of alcohol, but explored the wider impact on the community and gave advice on how to deal with situations or patients who presented within the pharmacy suffering from the effects of drug or alcohol misuse.
An alcohol awareness campaign was run in Glasgow, Scotland, in 2004 and was co-ordinated by the pharmaceutical public health team (E. Grant, personal communication). Approximately 100 community pharmacies participated. The main focus of the campaign was alcohol awareness, particularly the recommended units for men and women. A poster was produced in the Health Board's graphics department, and leaflets on units of alcohol in various drinks, sensible drinking and related topics such as depression, coping with caring and smoking were supplied to the pharmacies along with pens, balloons and key rings.
Excess alcohol consumption was one of six community pharmacy public health campaigns in Leeds, England, in 2006. A questionnaire was sent to the 156 pharmacies in the area and 56 pharmacists responded.18 Only 25% of respondents agreed that the campaign increased their pharmacy's activity around the topic, and 12% agreed that ‘elements of the campaign presented problems’. Spontaneous comments indicated that most pharmacies had not taken a proactive approach with the campaign.
Evidence for the effectiveness of brief interventions for reducing excess alcohol consumption
To supplement the evidence identified above, information was also included in this review regarding the use of brief interventions to reduce excess alcohol consumption conducted in non-pharmacy primary care settings. A Cochrane review has been published on this topic,14 comprising 28 randomised controlled trials and 7286 participants, only 499 (6.8%) of whom were women. The studies were conducted in general practice (n = 23) and emergency departments (n = 5). Brief interventions achieved statistically significant reductions in alcohol consumption, and were more effective with male participants compared with females, achieving a reduction of six units per week on average. Interventions of greater duration than ‘brief’ interventions achieved non-significant reductions in alcohol consumption.
As well as under-representation of female participants, young people and ethnic minorities were not well represented in these trials. Most trials were conducted in Western Europe or North America. Many studies reported large losses to follow-up.
An additional systematic review of trials in general practice19 concluded that universal screening of patients for alcohol misuse might not be an effective method of identifying harmful or hazardous drinkers.
There has been little evaluation of the long-term effect of brief interventions. Wutzke et al.20 conducted a 9-month and 10-year follow-up of a cohort of 554 hazardous or harmful drinkers recruited from primary care or health screening services in Australia. At 9 months, of the 89% participants who were followed up, those who had received the intervention had significantly lower weekly alcohol consumption than controls. At 10 years, 78% of the cohort was followed up and no difference was shown with alcohol consumption between intervention and control participants.
A cohort of 338 at-risk alcohol drinkers in Norway, who were originally randomised to one of three trial groups, reported the persistence of beneficial effects of brief interventions at 9-year follow-up.21 Only 73% (n = 247) of the original cohort was included, with differential follow-up across the original groups. Significant reductions in serum γ-glutamyltransferase were observed at follow-up compared with baseline for the entire cohort.