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- Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse
Full Report
- Research Review Jul. 10, 2012
Related Products for this Topic
- Research Protocol Jul. 22, 2011
- Disposition of Comments Report Dec. 7, 2012
Executive Summary – Jul. 10, 2012
Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse
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Table of Contents
- Background
- Screening and Behavioral Counseling
- Objective
- Methods
- Results
- Discussion
- References
- Full Report
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Alcohol misuse, which includes the full spectrum from drinking above recommended limits (i.e., risky/hazardous drinking) to alcohol dependence,1-3 is associated with numerous health and social problems and more than 85,000 deaths per year in the United States 1, 4 and an estimated annual cost to society of more than $220 billion.5, 6 Alcohol misuse is estimated to be the third leading cause of preventable mortality in the United States following tobacco use and being overweight.7 Alcohol misuse contributes to a variety of conditions, including hypertension, cirrhosis, gastritis and gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, and suicide.8, 9 Excessive alcohol consumption is a major factor in injury and violence.10
Definitions of the spectrum of alcohol misuse (i.e., unhealthy alcohol use3) continue to evolve. For the purposes of this report, we use the definitions described in Table A.
Risky or hazardous use
Consumption of alcohol above recommended daily, weekly, or per occasion amounts.1 Consumption levels that increase the risk for health consequences.
Harmful use11, 12
A pattern of drinking that is already causing damage to health. The damage may be either physical (e.g., liver damage from chronic drinking) or mental (e.g., depressive episodes secondary to drinking)
Alcohol abuse13
A. A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
Alcohol dependence13 (alcoholism, alcohol addiction)
A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
Though estimating the prevalence of alcohol misuse is challenging, it has been estimated that about 30 percent of the U.S. population is affected, with the majority of these individuals engaging in what is considered risky drinking.3 Older studies report a range of risky drinkers from 4 to 29 percent across primary care populations, with prevalence estimates of 0.3 to 10.0 percent for harmful drinkers and 2.0 to 9.0 percent for alcohol dependence.14 More recent data from the American Academy of Family Physicians National Research Network reveal that 21.3 percent of primary care patients reported risky/hazardous drinking (based on the three quantity and frequency questions from the Alcohol Use Disorders Identification Test [AUDIT-C]).15 Alcohol dependence has lifetime prevalence rates on the order of 17 percent for men and 8 percent for women;16 prevalence of current dependence (within the last 12 months and as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]) is approximately 4 percent in the general adult population.17 Some studies have reported that one in five of those who screen positive for unhealthy alcohol use in primary care will have alcohol dependence (four in five will not).18, 19 Rates of alcohol-use disorders among medical outpatients are similar to those seen in the general population and are generally higher in males and younger people of all races/ethnicities.14, 20
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has proposed epidemiologically based alcohol-use guidelines to limit risks for drinking-related consequences by establishing age- and sex-specific recommended consumption thresholds.21 Maximum recommended consumption is three or fewer standard drinks per day (seven per week) for adult women and for anyone older than 65 years of age, and four or fewer standard drinks per day (14 per week) for adult men. A standard drink is defined as one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits.22, 23 These guidelines do not apply to certain people (such as adolescents, pregnant women, and people with alcohol dependence or medical conditions or medication use) for whom alcohol intake is contraindicated, or to circumstances (driving) in which no consumption is considered safe.
Screening and Behavioral Counseling
Several screening questionnaires can be used to identify alcohol misuse. The most commonly studied instruments include AUDIT and its abbreviated versions (e.g., the AUDIT-C), the CAGE questionnaire (Cut-down, Annoyed, Guilty, Eye-opener), the Michigan Alcoholism Screening Test (MAST), and versions of the single-question screen.
Behavioral interventions and patient education are often used for patients who engage in less severe alcohol misuse (i.e., risky/hazardous drinking).1 Brief interventions, as shown in Table B, generally aim to moderate a patient's alcohol consumption to sensible levels and eliminate risky drinking practices, rather than insist on complete abstinence.
The assumption underlying brief behavioral counseling interventions in primary care is that, for identified risky drinkers, reducing overall alcohol consumption or adopting safer drinking patterns (that is, fewer drinks per occasion and not drinking before driving) will reduce the risk for medical, social, and psychological problems.26 Cross-sectional and cohort studies have consistently related high average alcohol consumption to short- or long-term health consequences.23, 27 A meta-analysis of studies examining the association between all-cause mortality and average alcohol consumption found that men averaging at least four drinks per day and women averaging two or more drinks per day experienced significantly increased mortality relative to nondrinkers.28 Studies also relate heavy per-occasion alcohol use (i.e., binge drinking) to acute injury risks and alcohol-related life problems.23, 27
Table B. What are brief behavioral counseling interventions delivered in primary care settings?
- Behavioral counseling interventions include the range of personal counseling and related behavior-change interventions that are employed in primary care to help patients change health-related behaviors.24
- Counseling here denotes a cooperative mode of work demanding active participation from both patient and clinician that aims to facilitate the patient's independent initiative.24
- SAMHSA defines brief intervention as "a single session or multiple sessions of motivational discussion focused on increasing insight and awareness regarding substance use and motivation toward behavioral change."25
- Range from very brief interventions within a primary care visit to multicontact interventions that entail multiple, often more lengthy, visits and nonvisit contacts over an extended period.1
- Can include the following elements: advice, feedback, motivational interviews of varying length and number, or cognitive behavioral strategies (e.g., self-completed action plans, written health education or self-help materials, drinking diaries, problem-solving exercises to complete at home).
SAMHSA = Substance Abuse and Mental Health Services Administration
The NIAAA and others encourage physicians to identify patients with alcohol-related risks or problems and to provide office-based brief interventions or referrals as needed.21, 29, 30 In everyday practice, screening and screening-related assessment procedures are necessary to identify the range of alcohol users in order to offer appropriate interventions.31, 32
Even so, few primary care clinicians use recommended screening protocols or offer screening and interventions, and rates of intervening for alcohol misuse remain low.32 Most patients who misuse alcohol receive care from their primary care provider, where they represent as much as one-fifth of patients seen, a proportion similar to that seen for diabetes and hypertension.9, 14
In 2004, the U.S. Preventive Services Task Force (USPSTF) developed recommendations for screening and behavioral counseling interventions in primary care to reduce alcohol misuse.33 The summary of the recommendations states:
- The USPSTF recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. Grade: B Recommendation (i.e., the USPSTF recommends that clinicians provide the service to eligible patients. The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms).
- The USPSTF concludes that the evidence is insufficient to recommend for or against screening and behavioral counseling interventions to prevent or reduce alcohol misuse by adolescents in primary care settings. Grade: I Statement (insufficient evidence to make a recommendation).
This report's main objective is to conduct a systematic review of the effectiveness of screening followed by behavioral counseling, with or without referral, for alcohol misuse in primary care settings, addressing seven questions (Table C). This new review differs from the report on which the USPSTF 2004 recommendations were based in the following ways: We allowed inclusion of screening and behavioral interventions for the full spectrum of alcohol misuse, as long as subjects were identified by screening in a primary care or primary care-like setting; we added referral as an intervention of interest and changed the title to reflect this; we expanded the eligible settings from traditional primary care to also include settings with primary care-like relationships (e.g., infectious disease clinics for people with HIV); and we added additional outcomes of interest to our inclusion/exclusion criteria and analytic framework (Figure A).
KQ = Key Question
|What is the direct evidence that screening for alcohol misuse followed by a behavioral counseling intervention, with or without referral, leads to reduced morbidity, reduced mortality, or changes in other long-term (6 months or longer) outcomes (e.g., health care utilization, sick days, costs, legal issues, employment stability)?
|How do specific screening modalities compare with one another for detecting alcohol misuse?
|What adverse effects are associated with screening for alcohol misuse and screening-related assessment?
|KQ 4a
|How do behavioral counseling interventions, with or without referral, compare with usual care for improving intermediate outcomes for people with alcohol misuse as identified by screening?
|KQ 4b
|How do specific behavioral counseling approaches, with or without referral, compare with one another for improving intermediate outcomes for people with alcohol misuse as identified by screening?
|What adverse effects are associated with behavioral counseling interventions, with or without referral, for people with alcohol misuse as identified by screening?
|How do behavioral counseling interventions, with or without referral, compare with one another and with usual care for reducing morbidity, reducing mortality, or changing other long-term (6 months or longer) outcomes (e.g., health care utilization, sick days, costs, legal issues, employment stability) for people with alcohol misuse as identified by screening?
|To what extent do health care system influences promote or hinder effective screening and interventions for alcohol misuse?
Figure A. Analytic framework for screening, behavioral counseling, and referral in primary care to reduce alcohol misuse
KQ = Key Question
The topic development and refinement processes were guided by the information provided by the topic nominator, a scan of the literature, methods and content experts, and Key Informants. Key Informants and Technical Expert Panel members participated in conference calls and discussions through email to review the analytic framework, Key Questions, search strategy, inclusion/exclusion criteria, research protocol, and to discuss the literature.
We searched MEDLINE®, Embase®, the Cochrane Library, CINAHL®, PsycINFO®, and the International Pharmaceutical Abstracts from January 1, 1985, to August 30, 2011. We used either Medical Subject Headings (MeSH) as search terms when available or keywords when appropriate, focusing on terms to describe the relevant population and the screening and behavioral interventions of interest. We limited searches to English-language publications.
We developed inclusion and exclusion criteria with respect to Populations, Interventions, Comparators, Outcomes, Timing, Settings, and study designs (PICOTS). We included studies enrolling adults and/or adolescents (ages 12 years or older) with alcohol misuse identified by screening in primary care settings or settings with a primary care-type relationship.
For Key Question 2, we focused on systematic reviews and meta-analyses, and we did not restrict the publication date. We supplemented the findings with information from other sources to fill in important gaps. For all other Key Questions, we included controlled trials published in 1985 or later and systematic reviews and meta-analyses published in the last 5 years that directly address our Key Questions. Studies of at least 6 months' duration were eligible. For Key Questions 1 and 3, we searched for studies that assigned patients to screening compared with another screening approach, no screening, or usual care. For Key Questions 4, 5, and 6, we searched for studies that assigned subjects that had a positive screening test to an intervention of interest and to at least one eligible comparator. For Key Question 7, studies included in any of the earlier Key Questions were eligible.
All titles and abstracts identified through searches were independently reviewed by two trained members of the research team. Studies marked for possible inclusion by either reviewer were retrieved for full-text review. Each full-text article retrieved was independently reviewed by two trained members of the team for final inclusion/exclusion. If the reviewers disagreed, conflicts were resolved by discussion with an experienced team member.
We designed and used structured data abstraction forms to extract pertinent information from each included article, including characteristics of study populations, settings, interventions, comparators, study designs, methods, and results. All data abstractions were completed by trained reviewers and then reviewed for completeness and accuracy by a second member of the team.
To assess the quality of studies, we used predefined criteria, based on those developed by the USPSTF34 and the University of York Centre for Reviews and Dissemination,35 rating studies as good, fair, or poor. Two independent reviewers assigned quality ratings for each study. Disagreements between the two reviewers were resolved by consulting an experienced member of the team.
When analyzing data for this report, we stratified evidence by population (adults, older adults, young adults/college students, and pregnant women). Quantitative analyses were conducted of outcomes reported by a sufficient number of studies that were homogeneous enough to justify combining their results. We used subgroup analyses to explore whether results differed by intensity, sex, country, provider delivering the intervention, or setting. The chi-squared statistic and the I2 statistic were calculated to assess statistical heterogeneity in effects between studies.36, 37 Heterogeneity was also explored through sensitivity analyses. When quantitative analyses were not appropriate (e.g., because of clinical heterogeneity, insufficient numbers of similar studies, or insufficiency or variation in outcome reporting), we synthesized the data qualitatively.
To assess the differential effects of interventions using more or less time and those using single or multiple contacts, we grouped interventions by intensity of counseling, as measured by duration and number of contacts: very brief (up to 5 minutes, single contact), brief (more than 5 and up to 15 minutes, single contact), extended (beyond 15 minutes, single contact), brief multicontact (each contact up to 15 minutes), and extended multicontact (some contacts beyond 15 minutes).
We graded the strength of evidence (SOE) as high, moderate, low, or insufficient based on established methods guidance.38 Two reviewers assessed each domain for each key outcome, and differences were resolved by consensus. We assessed applicability of the evidence following established methods guidance. We used the PICOTS framework to explore factors that affect applicability.
We included 44 published articles reporting on 29 studies: 23 randomized controlled trials (RCTs) and 6 meta-analyses or systematic reviews (Figure B). In the 23 included trials, sample sizes ranged from 72 to 1,559, and study duration ranged from 6 to 48 months. Eleven were conducted solely in the United States; 10 took place outside the United States, and the remaining 2 were conducted in a combination of U.S. and non-U.S. sites. We summarize the main findings for each Key Question by population and outcome, and report the SOE for each.
Key Question 1. What is the direct evidence that screening for alcohol misuse followed by a behavioral counseling intervention, with or without referral, leads to reduced morbidity, reduced mortality, or changes in other long-term (6 months or longer) outcomes?
We did not find any studies directly addressing this question.
Key Question 2. How do specific screening modalities compare with one another for detecting alcohol misuse?
We found adequate evidence that several screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity. A single-question screen (covering the past 12 months), AUDIT-C, and AUDIT appear to be the best overall instruments for screening adults for the full spectrum of alcohol misuse in primary care, considering sensitivity, specificity, and time burden. Several instruments require as little as 1 to 2 minutes to administer (e.g., single-question screens, AUDIT-C).
Single-question screens covering the past 12 months have reported sensitivities of 0.82 to 0.87 and specificities of 0.61 to 0.79 for detecting alcohol misuse in adults in primary care.
Figure B. Disposition of articles
M-A = meta-analysis; PICOTS = populations, interventions, comparators, outcomes, timing, settings or study duration;
SR = systematic review
When focusing on adequately sized U.S. studies that reported sensitivity and specificity of screening for the full spectrum of alcohol misuse in primary care, data suggest that some often recommended cut-points for screening (i.e., AUDIT≥8) may need to be revised. The AUDIT had sensitivity of 0.44 to 0.51 and specificity of 0.96 to 0.97 for identifying alcohol misuse in adults using a cut-point of ≥8; more optimal balance of sensitivity and specificity was seen at cutoffs of 4 or 5. The sensitivity and specificity at a cutoff of ≥4 were 0.84 to 0.85 and 0.77 to 0.84, respectively; and at a cutoff of ≥5 were 0.70 to 0.92 and 0.73 to 0.94, respectively. Further, sex-specific cutoffs may be warranted because sensitivities for women at cutoffs of ≥4 and ≥5 were 0.47 to 0.65 and 0.35 to 0.53, respectively, but improved to 0.70 to 0.79 at ≥3 (with specificity of 0.86 to 0.87).The CAGE has very low sensitivity for detecting risky/hazardous drinking and is therefore not a good screening test for identifying risky/hazardous drinking or for screening for the full spectrum of alcohol misuse.
For young adults and college students, the included systematic reviews identified only one study reporting the sensitivity and specificity of a screening instrument, the full AUDIT (≥8), which had a sensitivity of 0.82 and specificity of 0.78.
For pregnant women, the AUDIT-C performed better than other instruments for detecting both risky drinking and abuse or dependence, demonstrating both high sensitivity (0.95 or higher) and high specificity (up to 0.85).
The reference standard for the screening instruments was a structured diagnostic interview, generally including the timeline followback method39 or similar approaches to determine the quantity/frequency of consumption.
Key Question 3. What adverse effects are associated with screening for alcohol misuse and screening-related assessment?
We did not find any studies directly addressing this question.
Key Question 4a. How do behavioral counseling interventions, with or without referral, compare with usual care for improving intermediate outcomes for people with alcohol misuse as identified by screening?
Overall, evidence supports the effectiveness of behavioral interventions for improving several intermediate outcomes for adults, older adults, and young adults/college students (moderate or low SOE, depending on the population and outcome). For pregnant women, the one included study40 did not provide evidence of the effectiveness of behavioral interventions for improving intermediate outcomes over 6 months or longer (low or insufficient SOE, depending on the outcome), but it found higher rates of abstinence maintained for the subgroup of subjects who were abstinent pre-assessment for the intervention group compared with the control group. Table D summarizes findings for the three intermediate outcomes most commonly reported, by population. None of the included studies reported followup with referrals as an outcome.
Subgroup analyses did not identify differences between men and women. Brief multicontact interventions have the best evidence of effectiveness across populations, outcomes, and have followup data over several years. Our meta-analyses of studies in adults found very brief (up to 5 minutes) and brief (more than 5 minutes, up to 15 minutes) single-contact interventions to be ineffective for some outcomes and less effective than brief multicontact interventions for others.
Key Question 4b. How do specific behavioral counseling approaches, with or without referral, compare with one another for improving intermediate outcomes for people with alcohol misuse as identified by screening?
This Key Question addressed direct, head-to-head evidence comparing more than one specific behavioral intervention approach. We identified four RCTs enrolling adults and one enrolling college students. All five compared different types/intensities of interventions. Overall, head-to-head evidence from the five studies was insufficient to draw firm conclusions about whether specific types of interventions (i.e., different levels of intensity) differ in effectiveness for most intermediate outcomes of interest (insufficient SOE). None of the studies reported a statistically significant difference between the two groups of interest; for a few intermediate outcomes, some studies found no statistically significant difference between interventions (low SOE).
(Mean Drinks/Week)
|Heavy Drinking Episodesb
Drinking Limits
Reduction of 3.6 (2.4 to 4.8) from baseline ~23
12% fewer subjects reported heavy drinking episodes (7%, 16%), from ~52% at baseline
11% more subjects achieved (8%, 13%)
Older adults
Reduction of 1.7 (0.6 to 2.8) from baseline ~16
Insufficient SOE
9% more subjects achieved (2%, 16%)
Young adults or college students
Reduction of 1.7 (0.7 to 2.6) from baseline ~15
0.9 fewer heavy drinking days (0.3, 1.5) from ~6.2 days per month at baseline
Insufficient SOE
Pregnant women
Data from 1 study found no difference
Insufficient SOE
Insufficient SOE
Insufficient SOE
Insufficient SOE
Insufficient SOE
SOE = strength of evidence
Key Question 5. What adverse effects are associated with behavioral counseling interventions, with or without referral, for people with alcohol misuse as identified by screening?
We found no evidence of direct harms, aside from opportunity costs associated with the interventions, which ranged from a minimum of 5 minutes to a maximum of approximately 2 hours dispersed over multiple in-person and/or telephone visits (moderate SOE) (Table E).
Effect Size (95% CI)
|Strength of Evidence
Increased smoking
No difference between groups (unable to calculate effect size).
Opportunity costs/time
Range from about 5 minutes to approximately 2 hours dispersed over multiple in-person and/or telephone visits, depending on planned intervention intensity.
No difference between groups (unable to calculate effect size).
Stigma, labeling, discrimination, or interference with doctor–patient relationship
Evidence was insufficient to draw conclusions.
Illegal substance use
Evidence was insufficient to draw conclusions.
CI = confidence interval
Key Question 6. How do behavioral counseling interventions, with or without referral, compare with one another and with usual care for reducing morbidity, reducing mortality, or changing other long-term (6 months or longer) outcomes for people with alcohol misuse as identified by screening?
The tables below provide a summary of the main results for adults (Table F), older adults (Table G), and young adults and college students (Table H). For most health outcomes, available evidence either demonstrated no difference between interventions and controls (e.g., mortality: low SOE) or was insufficient to draw conclusions (e.g., accidents, injuries, alcohol-related liver problems: insufficient SOE). Some evidence suggests that interventions improve some utilization outcomes for adults (e.g., hospital days and costs: low SOE). Our meta-analyses did not find a reduction in all-cause mortality for adults (four studies; rate ratio 0.64, 95% confidence interval [CI], 0.24 to 1.7) or for all age groups combined (adults, older adults, and young adults/college students) (six studies; rate ratio 0.52, 95% CI, 0.22 to 1.2). Point estimates trended toward favoring behavioral interventions, few studies reported mortality, and there is little long-term data; additional studies would be needed to increase precision. We did not identify any studies enrolling pregnant women reporting outcomes for this question (insufficient SOE).
|Type of Outcomes
|Specific Outcome
Effect Size (95% CI)
|Strength of Evidence
Our meta-analyses did not find a reduction in all-cause mortality for adults (4 studies; rate ratio 0.64, 95% CI, 0.24 to 1.7a).
Alcohol-related accidentsb
Evidence was insufficient to draw conclusions.
Alcohol-related liver problems
Evidence was insufficient to draw conclusions.
Fewer hospital days in last 6 months for intervention group compared with the control group at 6, 12, and 48 months: 35 vs. 180, 91 vs. 146, and 420 vs. 664, p<0.001, p<0.001, and p<0.05, respectively.c
Emergency visits
Difference between groups for visits in past 6 months did not reach statistical significance.d
Primary care visits
No significant difference between intervention and control groups:
Over 12 months Project TrEAT reported a total potential economic benefit of the brief intervention of $423,519, including more than $190,000 savings in emergency department and hospital use and almost $230,000 in avoided costs of crime and motor vehicle accidents. Using data from 48-month followup, the authors reported an intervention cost per patient of $205, and a benefit per patient of $7,985, for a resulting benefit-cost ratio of 39 (95% CI, 5.4 to 72.5) (societal perspective).c,e
Legal problems
One 48-month RCT found no significant difference between the intervention and control groups for several legal problems,f but did report a difference for controlled substance/liquor violations, with 2 in the intervention group compared with 11 in control group (p<0.05).c
Quality of life
Three 12-month studies (total N=353) reported no difference between intervention and control groups for general quality of life measures.
CI = confidence interval; N = number; RCT = randomized controlled trial; TrEAT = Trial for Early Alcohol Treatment; vs. = versus; WMD = weighted mean difference
|Type of Outcome
|Specific Outcome
Effect Size (95% CI)
|Strength of Evidence
Evidence from 1 study was insufficient to draw conclusions.
Alcohol-related accidentsa
Evidence was insufficient to draw conclusions.
Alcohol-related liver problems
Evidence was insufficient to draw conclusions.
Evidence was insufficient to draw conclusions.
Emergency visits
Evidence was insufficient to draw conclusions.
Primary care visits
Evidence was insufficient to draw conclusions.
An economic analysis of Project GOAL found no significant difference in economic outcomes through 24 months.46 The total costs of health care and social consequences were estimated to be $5,241 (95% CI, $2,995 to $7,487) per patient in the intervention group and $6,289 (95% CI, $3,549 to $9,029) per patient in the control group.
CI = confidence interval, GOAL = Guiding Older Adult Lifestyle
|Type of Outcome
|Specific Outcome
Effect Size (95% CI)
|Strength of Evidence
One trial reported one death in the control group.
Motor vehicle events
A subgroup analysis (N=226) of young adults from Project TrEAT47 found fewer motor vehicle crashes with nonfatal injuries for those in the intervention group than for controls (9 vs. 20, respectively; p<0.05) and fewer total motor vehicle events (114 vs. 149; p<0.05) after 48 months of followup.
Alcohol-related liver problems
Evidence was insufficient to draw conclusions.
The subgroup analysis from Project TrEAT reported a lower number of days of hospitalization for the intervention group that did not reach statistical significance (131 vs. 150, p=NS).47
Emergency visits
The subgroup analysis from Project TrEAT reported fewer emergency department visits for the intervention group than for the control group (103 vs. 177, p<0.01).47
Primary care visits
Evidence was insufficient to draw conclusions.
Evidence was insufficient to draw conclusions.
Academic problems
Evidence from two trials (N=576 and N=104) conducted in New Zealand suggests that behavioral interventions result in fewer consequences related to academic role expectations (rate ratio between 0.70 and 0.80).48, 49
Legal problems
The subgroup analysis from Project TrEAT found no significant difference between the intervention and control groups for assault/battery/child abuse, resist/obstruct officer/disorderly conduct, criminal damage/property damage, theft/robbery, and other arrests, but did report a difference for controlled substance/liquor violations, with 0 in the intervention group compared with 8 in the control group (p<0.01).47
CI = confidence interval; N = number; NS = not sufficient; TrEAT = Trial for Early Alcohol Treatment; vs. = versus
Key Question 7. To what extent do health care system influences promote or hinder effective screening and interventions for alcohol misuse?
Interventions required sufficient support systems in order to provide screening and screening-related assessment, and in some cases, provider prompting. Such supports are likely required for effective screening and intervention. The country in which studies were conducted (United States compared with non-United States) did not have a significant impact on the effectiveness of interventions for consumption outcomes. Interventions conducted in academic/research-oriented settings and those conducted in community-based primary care settings were both effective for reducing alcohol consumption, with data showing a trend toward greater reduction for interventions delivered in academic/research-oriented settings (weighted mean difference [WMD], -5.0 drinks/week, 95% CI, -7.6 to -2.5) than for those delivered in community-based settings (WMD, -3.2, 95% CI, -4.3 to -2.2). Interventions delivered by primary care providers and by research personnel were both effective for reducing alcohol consumption, with data showing a trend toward greater reduction for interventions delivered mostly by primary care providers (WMD, -4.0 drinks per week, 95% CI, -5.4 to -2.6) than for those delivered primarily by research personnel (WMD, -3.0, 95% CI, -5.0 to -1.0). Just one intervention delivered by a nurse contributed to the drinks per week meta-analysis; the reduction in drinks per week was not statistically significant for that study (WMD, -0.2, 95% CI, -8.9 to 8.6). Two other studies that did not provide sufficient data for our drinks per week meta-analysis reported benefits of interventions delivered primarily by nurses,50, 51 or by nurses and physician assistants52 for some consumption outcomes. In addition, two interventions48, 49, 53 conducted via computer reported some evidence of effectiveness for college students.
Most interventions required training of providers and/or staff. Such training may be required for practices to deliver effective screening and interventions for alcohol misuse. When reported, training duration ranged from as little as 15 minutes54, 55 to as long as 6 to 8 hours,52, 56 full-day workshops,57 or a 4-week training in motivational interviewing principles.58 Nine studies43-45, 47, 50-52, 57-68 reported trainings of research staff and interventionists that were 30 minutes or longer and also provided feedback, booster sessions, or weekly conference calls to maintain adherence to protocol. Five others69-75 reported trainings of 30 minutes or more but did not provide information on booster sessions.
We aimed to conduct a systematic review of the effectiveness of screening followed by behavioral counseling for alcohol misuse in primary care settings. In the Background section, we describe several categories of alcohol misuse (i.e., risky/hazardous use, harmful use, alcohol abuse, and alcohol dependence). It is important to note that the categories are not all discrete categories (i.e., an individual may meet the definition for more than one category for some of these categories). It appears that the included trials of behavioral counseling generally enrolled subjects with risky/hazardous drinking, but the trials use varying terminology to describe the included populations and often enrolled heterogeneous populations (i.e., included subjects with various types of alcohol misuse). Nevertheless, the vast majority of trials excluded subjects with alcohol dependence or constructed inclusion/exclusion criteria to substantially limit the number of potential subjects with alcohol dependence.
Given the heterogeneity in terminology used by the included trials and the potential overlap of some categories of alcohol misuse, our best assessment is that our overall findings from behavioral counseling intervention trials are applicable to risky/hazardous drinkers, and are unlikely to be applicable to those with alcohol dependence. It is uncertain whether findings are applicable to harmful drinkers or people with alcohol abuse.
Summary of Main Findings
Screening for Alcohol Misuse
We found adequate evidence that several screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity. A single-question screen, AUDIT-C, and AUDIT appear to be the best overall instruments for screening adults for alcohol misuse in primary care, considering sensitivity, specificity, and time burden. Several instruments require as little as 1 to 2 minutes to administer (e.g., single-question screens, AUDIT-C). For people with positive screening tests, screening-related assessments are still necessary to determine whether an individual has risky/hazardous drinking or if they meet criteria for alcohol abuse or dependence.
None of the included systematic reviews provided information about the use of screening instruments in adolescents. Of note, our methods for identifying all potentially relevant studies for Key Question 2 have some limitations: we did not review all individual publications assessing screening instruments. Instead, we relied on previously published systematic reviews to find information, and we filled gaps with data from other sources (i.e., Technical Expert Panel members, peer and public reviewers, personal files).
Behavioral Counseling Interventions in Primary Care
All Adults (Age 18 and Older)
We found that behavioral counseling interventions improved intermediate outcomes (moderate SOE) and some utilization outcomes (including hospital days and costs, low SOE) for adults with alcohol misuse. For most health outcomes, available evidence either found no difference between interventions and controls (e.g., mortality, low SOE) or was insufficient to draw conclusions about the effectiveness of behavioral interventions compared with controls (e.g., alcohol-related liver problems, insufficient SOE).
We found an average reduction of 3.6 drinks per week for adults receiving interventions compared with those in control groups and an 11 percent increase in the percentage of adults achieving recommended drinking limits over 12 months. This translates to a number needed to treat (NNT) of 9.1 to get 1 person to change from risky/hazardous drinking to drinking recommended limits over 12 months with a behavioral intervention, and a range for the number needed to screen (NNS) of 31 to 227, depending on the prevalence of risky/hazardous drinking in the population (Table I). When using effectiveness data for brief (more than 5, and up to 15 minutes) multicontact interventions, these improve to an NNT of 6.7 and range of NNS from 23 to 167.
The evidence for effectiveness in adults is strongest for brief multicontact interventions; these studies consistently found statistically significant improvements in consumption, heavy drinking episodes, and achieving recommended drinking limits. The brief multicontact interventions were generally 10 to15 minutes per contact. The effect sizes for brief multicontact interventions were greater than for other intensities (although confidence intervals generally overlapped). In addition, the best studies show that the effect of brief multicontact interventions remains for several years of followup,44, 45, 66 and show improvement for some utilization outcomes (fewer hospital days44, 45) and costs (benefit-cost ratio of 39:1 over 48 months, 95% CI, 5.4 to 72.544).
Our meta-analyses of studies in adults found very brief (up to 5 minutes) and brief (more than 5, up to 15 minutes) single-contact interventions to be ineffective for some outcomes and less effective than brief multicontact interventions for others. Although extended multicontact interventions appear to be effective for improving intermediate outcomes, we did not find evidence that they are more effective than brief multicontact interventions.
Long-term outcomes up to 48 months revealed that participants in the intervention groups maintained reductions in consumption or continued to reduce consumption further, but differences between intervention and control groups were no longer statistically significant by 48 months. Studies identified relatively delayed reduction in consumption in control groups to levels achieved by the intervention group that could reflect the natural history of alcohol consumption, the cumulative effect of yearly followups with the health care system, attrition (if more subjects lost to followup from the control group were risky drinkers than those lost to followup from the intervention group), or (late) regression to the mean.
Our subgroup analyses found similar benefits for men and women and for studies conducted in the United States compared with those conducted in other countries. We found a trend toward a greater reduction in consumption for interventions delivered primarily by primary care providers (WMD, 4.0 drinks/week, 95% CI, 2.6 to 5.4) than for those delivered primarily by research personnel (3.0 drinks/week, 95% CI, 1.0 to 5.0); and for interventions delivered in academic/research-oriented settings (WMD, 5.0 drinks/week, 95% CI, 2.5 to 7.6) than for those delivered in community-based settings (3.2 drinks/week, 95% CI, 2.2 to 4.3).
Older Adults
Two studies enrolling older adults provided evidence of the effectiveness of behavioral interventions for reducing consumption and improving the percentage drinking beneath recommended limits, but effect sizes were smaller than those found for all adults (Table B). Evidence for health outcomes was insufficient to draw conclusions.
Young Adults and College Students
We found evidence of effectiveness of behavioral interventions for improving intermediate outcomes and some accident, utilization, and academic outcomes (Tables B and H), including fewer motor vehicle events, hospitalization days, and emergency department visits for those in the intervention group compared with the control group (low SOE).47 Unlike studies in adults, which generally found benefits to last for several years for intermediate outcomes, some benefits of interventions for college students found at 6 months were no longer statistically significantly different for intervention versus control groups at 12 months. This could be due to the natural history of drinking among college students or could indicate the need for additional booster sessions to maintain benefits.
|Lower Estimate of Range
|Upper Estimate of Range
|NNS = number needed to screen; NNT = number needed to treat
aNumber identified from screening and screening-related assessment; a range of risky drinkers (4% to 29%) has been found across multiple primary care populations, with prevalence estimates of 2.0% to 9.0% for alcohol dependence.14 The prevalence of risky drinking and alcohol dependence are not linked in this table. In other words, although the prevalence of 4% for risky drinking and 2% for alcohol dependence are in the same column (as are 29% and 9%, respectively), there are no data to suggest that the prevalence of dependence is 2% when the prevalence of risky drinking is 4%.
bBased on absolute difference of 11% (that would achieve recommended drinking limits) from our meta-analysis including interventions of all intensity.
cBased on absolute difference of 15% (that would achieve recommended drinking limits) from our subgroup meta-analysis for brief multicontact interventions.
Notes: Data in table are number of people unless specified as percentage; the 1,000 people screened are those that have not been previously screened and have no known history of alcohol misuse. The scenario in this table is optimistic, because it assumes that screening identifies all those with alcohol misuse (100% sensitive) and that all those identified with misuse potentially get an intervention. We conducted sensitivity analyses to explore how NNT and NNS would change using other assumptions. The NNT does not change much using a variety of different assumptions; it ranges from 6.7 to 18.2. Using a sensitivity of 81% for the screening instrument (representative of the single question19) changes the NNS range to 39 to 281 (from 31 to 227). If only half of all those with a positive screening test receive an intervention, then the NNS range increases to 63 to 455. If 90% of those with a positive screen receive an intervention, the NNS range increases to 35 to 253. If the screening instrument sensitivity is 81% and only half of those with a positive screen receive an intervention, then the NNS range increases to 155 to 1,122.
|Prevalence of risky/hazardous drinkinga
|People identified with risky/hazardous drinkinga
|Potential behavioral interventions delivered
|People achieving recommended drinking limits by 12 months with behavioral interventionb
|NNT to get 1 person to change from risky/hazardous drinking to drinking recommended amounts with behavioral interventionb
|NNS to get 1 person to change from risky/hazardous drinking to drinking recommended amounts with behavioral interventionb
|People achieving recommended drinking limits by 12 months with brief multicontact behavioral interventionc
|NNT to get 1 person to change from risky/hazardous drinking to drinking recommended amounts with brief multicontact behavioral interventionc
|NNS to get 1 person to change from risky/hazardous drinking to drinking recommended amounts with brief multicontact behavioral interventionc
|Prevalence of alcohol dependencea
|People identified with alcohol dependencea
Pregnant Women
We found just one study enrolling pregnant women (N=250)40 that met our inclusion criteria. The study did not find a significant difference for reduction in consumption (low SOE), but found higher rates of abstinence maintained for subjects who were abstinent pre-assessment for the intervention group compared with the control group.
Our searches identified other studies focusing on pregnant women that did not meet our inclusion criteria.76-93 Several did not take place in a primary care setting, but instead were conducted in other settings, such as those that included jails and specialized drug and alcohol treatment centers; these included, for example, the Project CHOICES study.84 Others were excluded because they did not include a control group or because they followed participants after the intervention for less than 6 months.82, 93 Several of these studies reported benefits of behavioral interventions for pregnant women, including reduction of alcohol consumption,82, 93 reduced risk of an alcohol-exposed pregnancy,84 higher rates of abstinence,88 and better fetal and newborn outcomes (birthweights and birth lengths, and fetal mortality rates).88
Potential Adverse Effects of Behavioral Counseling Interventions
Published trials have given little attention to potential adverse effects of screening and behavioral counseling interventions for alcohol misuse. We found no trials reporting on illegal substance use, stigma, labeling, discrimination, or interference with the doctor-patient relationship. We found very limited evidence reporting no difference between intervention and control groups for smoking rates and anxiety (lowSOE).
The time required for interventions used in the included studies ranged from a minimum of 5 minutes to a maximum of approximately 2 hours dispersed over multiple in-person and/or telephone visits (moderateSOE). The brief multicontact intervention used in Project TrEAT (which provides some of the best evidence of effectiveness of behavioral interventions for risky/hazardous drinking in primary care) required two 15-minute visits with the primary care physician 1 month apart and two followup phone calls from a nurse.
Although trial data are limited regarding adverse effects of screening and behavioral interventions for alcohol misuse in primary care settings, other types of studies may offer some insights. Among a group of 24 general practitioners in Denmark who were interviewed about their participation in a screening and brief intervention program for alcohol misuse, nearly all reported experiencing negative reactions from some patients.94 Such reactions ranged from feelings of uneasiness or embarrassment to finding another physician. The physicians themselves noted that the added work of screening and brief intervention was onerous and hampered the establishment of rapport with patients. They also expressed concerns that screening identified people for whom intervention was unnecessary, yet took valuable time and resources, while at the same time failing to detect and help some for whom alcohol misuse was a real problem. However, other studies have found that patients view screening favorably, even perceiving higher quality of care when screening is followed by counseling.95 For example, one prospective cohort study found that communication and whole-person knowledge were perceived as better among patients who were counseled about their alcohol misuse compared with those who were not counseled.96
Treatments for Alcohol Dependence
Although we did not systematically examine the efficacy/effectiveness of various treatments for alcohol dependence (Table J), we provide contextual information regarding such treatments because screening for alcohol misuse will inevitably identify some individuals with alcohol dependence; thus, providers and those making recommendations need some information about whether there are effective interventions available for alcohol dependence. However, a detailed review and comparison of treatments for alcohol dependence are beyond the scope of this review.
Table J. Treatments for alcohol dependence
- Cognitive behavioral therapy
- Motivational enhancement therapy
- 12-step programs (e.g., Alcoholics Anonymous)
- Intensive outpatient programs using group or individual counseling
- Alcoholism treatment centers
- Pharmacotherapya (disulfiram, naltrexone, acamprosate)
- Detoxification (inpatient, residential, day treatment, or outpatient)
aPharmacotherapy can be used in addition to psychosocial therapy but is not recommended for use alone.
Note: this is not an exhaustive list of all treatments that have been studies or used for alcohol dependence but rather includes the most common.
Very few studies have examined the efficacy of brief interventions for alcohol dependence in a primary care setting. A systematic review of the literature concluded that there was no evidence for efficacy of brief behavioral interventions for patients with alcohol dependence in a primary care setting.97 Similarly, our review did not find any studies demonstrating efficacy of behavioral interventions for people with alcohol dependence in a primary care setting; studies included in our review that enrolled more than 10 percent of subjects with alcohol dependence reported behavioral interventions to be less effective or ineffective compared with studies not enrolling subjects with alcohol dependence. Thus, whereas the overall evidence for the effectiveness of treatment for alcohol dependence is considerable,98 the same cannot be said for the effectiveness of brief interventions for alcohol dependence in primary care settings.
Studies of pharmacotherapy for patients with alcohol dependence have generally enrolled subjects responding to advertisements or those being treated in specialty alcohol treatment centers. We were unable to identify any double-blind RCTs of pharmacotherapy that identified subjects by screening in a primary care setting or that assessed the efficacy or comparative effectiveness of pharmacotherapy in a primary care setting. Further, we were unable to identify any studies of pharmacotherapy for people with risky/hazardous drinking.
The findings are generally applicable to people with risky/hazardous drinking identified by screening in primary care settings (see beginning of Discussion). It is uncertain whether findings are applicable to harmful drinkers or people with alcohol abuse. Most studies excluded all or most potential subjects with alcohol dependence; thus, our findings for behavioral interventions in primary care settings likely do not apply to people with alcohol dependence, who probably require other treatments (e.g., referred for specialty treatment). Compared with the results of studies that enrolled few or no subjects with alcohol dependence, our subgroup analyses found that studies enrolling 10 percent or more subjects with alcohol dependence found behavioral interventions to be ineffective or less effective. This supports the theory that people with alcohol dependence are not likely to respond to the types of interventions evaluated in this report.
We did not identify any studies in adolescent populations or any conducted exclusively among veterans, and the results thus have uncertain applicability to these populations. We did, however, identify a sufficient number of studies of young adults/college students and older adults to draw conclusions (of lowto moderate strength) for several intermediate outcomes for these populations. Although we searched for studies conducted in settings with primary care-like relationships (e.g., nontraditional primary care settings such as infectious disease clinics for people with HIV), we did not find any, and our results have uncertain applicability to such settings.
All interventions required support systems to provide screening and screening-related assessment, and, in some cases, provider prompting. Screenings to identify subjects for the included studies were often extensive, multistep processes that included face-to-face interviews lasting up to 30 minutes by research personnel. Less time would be required for screening and screening-related assessments in primary care practice; we estimate less than 2 minutes for negative screens and 5 to10 minutes for positive screens, with most of the time for screening-related assessment to determine whether the patient has an alcohol use disorder as opposed to risky/hazardous drinking. Nevertheless, supports are likely required for effective screening and intervention. In addition, most interventions required training of providers and/or staff. Such training may be required to ensure that practices conduct effective screening and interventions for alcohol misuse.
Effective interventions were generally delivered either completely in person or also included phone followups. However, one study of adults in Germany demonstrated some benefits resulting from a telephone-based intervention,58 and two studies conducted in college student populations demonstrated benefits resulting from Web-based interventions delivered via computer.48, 49, 53
It is unclear whether our findings are applicable to people with comorbid medical or psychiatric conditions, including those with multiple substance use disorders, and some researchers have suggested that brief behavioral interventions may be ineffective or less effective in people with comorbid psychiatric conditions. A subgroup analysis (N=88) from a study conducted in Germany found that brief interventions did not significantly reduce drinking for subjects with comorbid anxiety and/or depression.60
We did not find any evidence that would inform decisions about the appropriate frequency of screening (i.e., whether it should be done annually, every 5 years, or something else).
The scope of this report is limited to primary care settings. Emergency departments or other health care settings may also offer opportunities to provide behavioral interventions to reduce alcohol misuse.
Studies were generally not designed to assess the impact of the interventions on morbidity and mortality; their focus was primarily on behavioral outcomes. In addition, most of the evidence we identified in this report was in the form of intermediate outcomes that rely on self-report of alcohol use. Some studies verified self-report using collaterals, such as a family member. Although there are no biomarkers accurate enough to be widely accepted to measure changes in alcohol use, self-report of alcohol use has been found to be accurate if collected carefully.99, 100 Nevertheless, it remains a concern that social desirability bias could play a role in the results of the included studies (i.e., although self-report is from both randomized groups in these studies, the group that gets more attention and advice to decrease their drinking may be more likely to report that they decreased their drinking).
It is possible that the assessments of alcohol misuse conducted in the included trials conceal therapeutic benefits of the behavioral interventions (i.e., bias results toward the null). Many studies included extensive assessment of alcohol-related behaviors, which could directly result in behavior changes. The control groups in the included studies generally reduced alcohol consumption. Some possible explanations for changes in behavior as a result of the screening and screening-related assessment include (1) increased awareness of the extent of their drinking; (2) the screening questions prompted them to discuss drinking with their primary care provider at a subsequent visit; (3) receipt of some minimal intervention, such as printed educational materials about general health or about alcohol specifically (control groups in the included studies often received some printed materials); or (4) regression to the mean. One study empirically tested whether brief assessment (without a behavioral intervention) reduces hazardous drinking by comparing brief assessment with a control that did not include assessment. The study concluded that assessment appears to reduce hazardous drinking but noted a potential limitation of measurement artifact due to social desirability bias.53
Future Research
Several gaps in the evidence were identified that could be potential targets for future research (see full report for details).
Behavioral counseling interventions improve intermediate outcomes (i.e., alcohol consumption, heavy drinking episodes, drinking above recommended amounts: moderate SOE) and some health care utilization outcomes (including hospital days and costs: lowSOE) for adults with risky/hazardous drinking. For most health outcomes, available evidence either found no difference between interventions and controls (e.g., mortality: lowSOE) or was insufficient to draw conclusions about the effectiveness of behavioral interventions compared with controls (e.g., alcohol-related liver problems, alcohol-related accidents, quality of life: insufficient SOE). Brief multicontact interventions (usually 10 to 15 minutes per contact) have the best evidence of effectiveness for adults (compared with very brief single-contact or brief single-contact interventions).
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- Chang G, Goetz MA, Wilkins-Haug L, et al. A brief intervention for prenatal alcohol use: an in-depth look. J Subst Abuse Treat. 2000 Jun; 18(4):365-9. PMID: 10812310.
- Chang G, Goetz MA, Wilkins-Haug L, et al. Identifying prenatal alcohol use: screening instruments versus clinical predictors. Am J Addict. 1999 Spring; 8(2):87-93. PMID: 10365188.
- Chang G, Wilkins-Haug L, Berman S, et al. Alcohol use and pregnancy: improving identification. Obstet Gynecol. 1998 Jun; 91(6):892-8. PMID: 9610992.
- Chang G, McNamara TK, Orav EJ, et al. Brief intervention for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005 May; 105(5 Pt 1):991-8. PMID: 15863535.
- Chang G, McNamara TK, Orav EJ, et al. Brief intervention for prenatal alcohol use: the role of drinking goal selection. J Subst Abuse Treat. 2006 Dec; 31(4):419-24. PMID: 17084796.
- Floyd RL, Sobell M, Velasquez MM, et al. Preventing alcohol-exposed pregnancies: a randomized controlled trial. Am J Prev Med. 2007 Jan; 32(1):1-10. PMID: 17218187.
- Flynn HA, Marcus SM, Barry KL, et al. Rates and correlates of alcohol use among pregnant women in obstetrics clinics. Alcohol Clin Exp Res. 2003 Jan; 27(1):81-7. PMID: 12544010.
- Grant TM, Ernst CC, Streissguth A, et al. Preventing alcohol and drug exposed births in Washington state: intervention findings from three parent-child assistance program sites. Am J Drug Alcohol Abuse. 2005; 31(3):471-90. PMID: 16161730.
- Meberg A, Halvorsen B, Holter B, et al. Moderate alcohol consumption—need for intervention programs in pregnancy? Acta Obstet Gynecol Scand. 1986; 65(8):861-4. PMID: 3825527.
- O'Connor MJ, Whaley SE. Brief intervention for alcohol use by pregnant women. Am J Public Health. 2007 Feb; 97(2):252-8. PMID: 17194863.
- Reynolds KD, Coombs DW, Lowe JB, et al. Evaluation of a self-help program to reduce alcohol consumption among pregnant women. Int J Addict. 1995 Mar; 30(4):427-43. PMID: 7607777.
- Centers for Disease Control and Prevention. Motivational intervention to reduce alcohol-exposed pregnancies—Florida, Texas, and Virginia, 1997-2001. MMWR Morb Mortal Wkly Rep. 2003 May 16; 52(19):441-4. PMID: 12807086.
- Halmesmaki E. Alcohol counselling of 85 pregnant problem drinkers: effect on drinking and fetal outcome. Br J Obstet Gynaecol. 1988 Mar; 95(3):243-7. PMID: 3370196.
- Waterson EJ, Murray-Lyon IM. Preventing alcohol related birth damage: a review. Soc Sci Med. 1990; 30(3):349-64. PMID: 2408151.
- Handmaker NS, Miller WR, Manicke M. Findings of a pilot study of motivational interviewing with pregnant drinkers. J Stud Alcohol. 1999 Mar; 60(2):285-7. PMID: 10091968.
- Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ. 2002 Oct 19; 325(7369):870. PMID: 12386040.
- Johnson M, Jackson R, Guillaume L, et al. Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health (Oxf). 2011 Sep; 33(3):412-21. PMID: 21169370.
- Saitz R, Horton NJ, Cheng DM, et al. Alcohol counseling reflects higher quality of primary care. J Gen Intern Med. 2008 Sep; 23(9):1482-6. PMID: 18618204.
- Saitz R. Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking. Drug Alcohol Rev. 2010 Nov; 29(6):631-40. PMID: 20973848.
- Miller WR, Walters ST, Bennett ME. How effective is alcoholism treatment in the United States? J Stud Alcohol. 2001 Mar; 62(2):211-20. PMID: 11327187.
- Babor TF, Steinberg K, Anton R, et al. Talk is cheap: measuring drinking outcomes in clinical trials. J Stud Alcohol. 2000 Jan; 61(1):55-63. PMID: 10627097.
- Del Boca FK, Noll JA. Truth or consequences: the validity of self-report data in health services research on addictions. Addiction. 2000 Nov; 95 Suppl 3:S347-60. PMID: 11132362.
Full Report
This executive summary is part of the following document: Jonas DE, Garbutt JC, Brown JM, Amick HR, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond ER, Yeatts J, Swinson Evans T, Wood S, Harris RP. Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse. Comparative Effectiveness Review No. 64. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 12-EHC055-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
For More Copies
For more copies of Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse: Comparative Effectiveness Review Executive Summary No. 64 (AHRQ Pub. No. 12-EHC055-1), please call the AHRQ Publications Clearinghouse at 1-800-358-9295 or email email@example.com.


text:
read reviews [4]
Yields 12 muffins
These gluten-free muffins are decadent and extremely moist, showing off the delicious flavors of banana, dark chocolate, buckwheat, and hazelnut — always a winning combination.
Toast the hazelnuts in a frying pan over medium heat for about 4 to 5 minutes, or until lightly browned and fragrant. Place them in a clean kitchen towel and rub them to remove the skins. When they are cool enough to be handled, chop them coarsely; set aside.
Preheat the oven to 350º F. Line a muffin pan with 12 paper liners, or use silicone muffin molds.
In the bowl of a stand mixer, beat the eggs with the sugar until light and pale in color. Stir in the melted butter and the yogurt. In another bowl, combine the flours, salt, baking powder, and baking soda. Stir the dry ingredients into the egg mixture, until just combined. Add the bananas, hazelnuts, and chopped chocolate, and mix gently.
Divide the batter among the muffin cups, place in the oven, and bake for 25 to 30 minutes, until the blade of a sharp knife inserted in the middle of the muffins comes out almost dry. Remove from the oven and let cool briefly, then invert onto a cooling rack to cool completely.
If you freeze some of the muffins, reheat them for 1 minute in the microwave, or for a few more minutes if you use a toaster oven or an oven preheated to 300ºF (150ºC). They'll be as if they were coming fresh out of the oven. Think about all of that melting chocolate.
Photo: Béatrice Peltre
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subset: commoncrawl


text:
The St. Ann Wal-mart has the Build your own Lightsaber kits for $33.
The St. Ann Wal-mart has the Build your own Lightsaber kits for $33.
Florissant Kmart has the Anakin Evolution sets They had 4 left at 5:45.
The also had the luke/leia, maul/dooku,solo/fett and amidala/3po Mpire sets
Woohoo! Thank you very much! They still had 2 on Sunday so I picked one up. 23.49 Ouch!!! But at least I've got it, this is one I've been wanting since I first saw it.
One question, did your's have an eye scar on Anakin III? Cause mine doesn't and I didn't notice until I was gone so I didn't look at the other one to see.
I didn't see any with an eye scar. I wasn't very enthusiastic about the extra $, but it was the 1st thing I've found that I wanted to buy for about 2 weeks.
South County TRU has the ventress unleashed wave. They also had 2 of the clone packs with green trooper. The packaging was in pretty bad shape for the most part.
There was a fair number of the 2 packs with the AT-TE gunner for anyone who missed it and doesn't mind a Bail Organa. They also had the build your own saber set on the endcap.
Kirwood target has the Tarkin wave (minus Tarkin, didn't see any) and the Antilles wave.
They also had restocks on both Royal Guards and the AT-TE gunner.
Kirkwood wal-mart was a waste of time.
Kirkwood Target has reset and has 500th vaders and Jedi Vs Sith packs. The multipacks were listed at $25. I thought they were going to be $20. They had 4 of them at 11:30. The nearby Wal-mart and TRU had nothing new.
South County has the Obi-wan fighter w/ Figure at $24.99.
Boone's Crossing Wal-mart has #55 obi-wan. At least 3 at 12:00. Didn't see any of the others from that wave.
Ferguson WM had a ton of the black clone pilots and at least Ventress and Palp/Yoda of the new Unleashed wave (top shelf, couldn't see behind) and Florissant Target had one each of the AT RT Driver and Tarkin. (All as of this morning)
I don't normally point people from one site to another but there's a lot more local guys posting here...


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iRhythms A-9800 Passive Noise Reducing Ear Bud Headphones
Passive noise reducing ear bud headphones for iPod, white with acrylic finish, 3 sets of custom fit ear sleeves, 1 set of foam fitted ear sleeves, in-line volume control, travel pouch, 9mm neodymium drivers
Snuggbuds Fusion
Our Fusion model provides a "full range" of sound, with excellent highs, mids, and lows in these speakers. Fusion for SmartPhone comes with a full-control mic for iPhone, fabric, tangle-free cord, and 90-degree gold-plated sport jack. Note: this microphone also works with other SmartPhones that accept direct-connect 3.5mm jacks, but click control function may not with all SmartPhones.


text:
The K2 Lite theme has two new layout options (left-sidebar and full-width), and three new widget areas in the footer.
Fjords now has clickable header area
The entire header area in the Fjords theme is now a link that points to your homepage.
Tiger Lily Color Scheme for Bouquet
The Bouquet theme now has a Tiger Lily orange color scheme.
Toggle Feed Links in MistyLook
The MistyLook theme now gives you the option to turn the feed links in the header on or off.
Featured Header Images for ChaosTheory
The ChaosTheory theme now has support for Featured Header Images.
Coraline has a One-Column Layout Option
The Coraline theme now has a one-column layout option.
Light Color Scheme for Modularity Lite
The Modularity Lite theme now has a light color scheme.
Five New Color Schemes for Coraline
The Coraline theme is now available in blue, brown, pink, purple, and red!


text:
Alright then. I have access to a hot air station. Where would I obtain solder paste and an appropriate syringe?
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text:
Over the past 25 years, the Cerro Gordo County Department of Public Health has developed a strong public health system that supports healthy communities and advances our county toward preventing illness, disease, and injury. Our Department provides over 50 services to Cerro Gordo County residents. Our staff is highly trained, exceptionally skilled, and fully committed to providing the highest quality service to all residents.
The accomplishments of the Cerro Gordo County Department of Public Health over the last 25 years are significant. Looking ahead, we will continue to make similar strides in the future to further advance the health of our county.
Office Hours:
Walk-In Immunization Clinic Hours:
10AM-Noon & 12:30-4PM


text:
Championship round-up
Boro maintain unbeaten record to go top as Brighton lose
By Graeme Bailey - Tweet me: @skygraemebailey. Last Updated: 17/09/11 6:28pm
Emnes: Winner at Selhurst Park
Sky Bet
Football Betting
Football Betting
Bet with Sky Bet
Middlesbrough moved top of the Championship after a 1-0 win at Crystal Palace as Brighton lost their unbeaten record as they lost at Leicester.
Click below for individual match reports:
Barnsley 1-1 Watford
Blackpool 1-1 Cardiff
C Palace 0-1 Middlesbrough
Hull City 1-0 Portsmouth
Leicester 1-0 Brighton
Leeds v Bristol C
Millwall 0-0 West Ham
N Forest 1-2 Derby
Peterborough 2-1 Burnley
Reading 2-0 Doncaster
With Southampton not playing until Sunday, Boro now find themselves on top of the pile as Marvin Emnes won it for them with a volley midway through the second-half.
Brighton lost for the first time this season at Leicester City with Yuki Abe scoring just after the break.
Derby and West Ham then follow, with both teams playing derbies earlier in the day. The Rams saw off Nottingham Forest in their East Midlands clash with youngster Jeff Hendrick scoring late on.
Sam Allardyce's Hammers played out a goalless draw with Millwall at the New Den.
There is still nothing separating Cardiff in sixth and Blackpool directly beneath them as they drew 1-1 at Bloomfield Road.
Leeds United moved into the top half of the table as Ross McCormack's late goal gave them a 2-1 win over Bristol City at Elland Road.
Burnley's poor form continued at London Road as they lost 2-1 to Peterborough United with Emile Sinclair grabbing a brace for the Posh.
Reading climbed off the bottom and sent Doncaster to the foot of the table as they beat Rovers 2-0 at the Madejski Stadium.
Robert Koren's first-half goal gave Hull City a 1-0 win over Portsmouth at the KC Stadium.
Finally, Barnsley came from behind to claim a 1-1 draw with Watford at Oakwell.


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Have you seen them?
The northern lights are spectacular and Iceland is the ideal place to search for this natural phenomenon. Sightings are most likely in the evening hours during the months of September to March. NASA predicts that this winter the northern lights will be their most intense in over a decade. To read more check out this article from The Telegraph.


text:
Discontinued Product
1.42 Cu. Ft. Stainless Steel Upright Medical Freezer
Sorry, the manufacturer is no longer producing this product.
Description & Highlights
Summit 1.42 Cu. Ft. Stainless Steel Upright Medical Freezer - Stainless Steel
For ultra low temperatures and medical freezer capabilities in a space-efficient design, choose the Summit 1.42 Cu. Ft. Stainless Steel Upright Medical Freezer (FS22LCSS). The entire cabinet of this compact cube freezer is wrapped in durable and high quality 304 grade stainless steel, priming it to withstand years and years of use while separating itself from other medical freezers that are typically plain white. Despite the freezer's minimal footprint, it still packs in almost a foot and a half of cubic feet in storage space for your temperature-sensitive items.
Capable of creating interior temperatures as low as -20ºC, this compact upright medical freezer will ensure proper storage of important items that require very specific and exceptionally low temperatures, such as vaccines. Adjusting the temperature is easy with use of the rear-mounted thermostat that prevents accidental changes. Inside you'll find a single-piece interior liner for a seamless covering that is very easy to clean, and a wire shelf for organizing your contents. The door is reversible for increased installation options and features a factory-installed, integrated keyed lock for increased security of important and valuable contents.
Stainless Steel Construction:The freezer is wrapped in high-quality 304 grade stainless steel that provides increased durability and a professional appearance
Compact Design:The small footprint of this medical freezer allows placement on countertops and tight spaces where others won't fit
Capable of Reaching -20ºC:Ideal for medical and commercial purposes with a minimum temperature rating of -20ºC
- Model: FS22LCSSSummit 1.42 Cu. Ft. Stainless Steel Upright Medical Freezer
- Brand: SummitFully finished cabinet
- All-freezer for medical or commercial useComplete 304 grade stainless steel construction
- Freestanding applicationFactory-installed keyed lock
- Compact footprintManual defrost
- Minimum temperature of -20ºC100% CFC-free
- Rear-mounted adjustable thermostatInput Voltage: 115 V/60 Hz
- One (1) wire shelf includedPower: 1.2 A
- One-piece interior linerWeight: 40 lbs
- Reversible doorInterior Dimensions: 14.63" H x 12.38" W x 14.5" D
- Warranty: 1 year parts & labor; 5 years compressorExterior Dimensions: 20.18" H x 17.38" W x 19" D
Interior Dimensions:
- Height: 14.63"
- Width: 12.38"
- Depth: 14.5"
Exterior Dimensions:
- Height: 20.18"
- Width: 17.38"
- Depth: 19"


text:
If you crave homemade quality without the usual quantity, this fudgy dessert for two is just for you!
Baking cocoa is dried chocolate liquor, with the cocoa butter removed, that is ground into unsweetened cocoa. Cocoa drink mixes have added powdered milk and sugar and are not a substitution for baking cocoa.
To determine if a casserole is 24 ounces, measure 3 cups water and pour into the casserole; there should still be at least an inch of space to the top of the casserole.
© 2017 ®/TM General Mills All Rights Reserved


text:
January 18, 2014
Stories this photo appears in:
Missoula Children's Theatre to host Monday auditions for Craig kids
The Missoula Children's Theatre will be returning to Craig with another week-long, intensive program for young thespians. This year's feature will be "Blackbeard the Pirate," and auditions are Monday afternoon at the Moffat County High School auditorium.
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text:
Each spring I run a Learn To Hunt event. I can schedule it for whenever I want, but I usually do it the weekend before the statewide youth hunt. In 2013 that is the first weekend in April. The problem is March 31, the weekend before is Easter weekend. We have had it on Easter weekend before, but most kids can't hunt much on that Sunday. So now I have 3 choices. Either I move the hunt a week earlier or just go with the 30 & 31, or do it 29-31 as most kids don't have school on Good Friday, and a lot of mentors don't have to work. The problem with a week earlier is that the weather can be so unpredictable then. Looking forward to getting some opinions.
Also I am always looking for mentors, so if any of you all would like to hunt another weekend by taking out a kid, let me know.


text:
Full Credits
- Uploader
Additional Credits
Lyrics/singing: Dustin McLean
Voices: Jonah Ray, Priscilla McLean
Stats & Data
[Whispering and Mumbling] [Music Playing]
[Door Slams]
Jonah Ray: Eh, eh, eh, eh. I'm returning a book.
Priscilla McLean: Huh? Oh, it's you.
Jonah Ray: Doo, doo, doo. Doo, doo, doo, doo, doo.
Priscilla McLean: Shh! Be quiet!
[Chimpanzee Sounds]
Jonah Ray: That's a lot of books!
Jonah Ray: It sure is.
Jonah Ray: Oof! Ugh!
Dustin McLean: I've got a stack of books to return. I wish that they were better. Now, I'm singing in the library and trying to flirt. Why'd that janitor walk there?
Dustin McLean: The monkey's reading. Let me help with the books. You have really big glasses.
Dustin McLean: I'm acting really bashful while I'm singing to you. Oh, I won't go away. No, I just won't go away.
Dustin McLean: Now, I'll walk away and head over here. I'll check the files out when I get over here. When I open this the cards all fly out. I saw Ghostbusters this copied that. Now, now, now, play the keyboard.
[Music Playing]
Dustin McLean: Is that Dave Coulier?
Dustin McLean: Throw this away.
Dustin McLean: I'm looking for a specific book. Bout a Rabbi and black guy. I'm peeking through the books and I won't leave you alone. And now, I'll float to the next level.
Jonah Ray: In a magic chair.
Dustin McLean: What's happening with that monkey? What is with this gas mask? This is a strange library.
Jonah Ray: I think it's dumb.
Dustin McLean: I'm gonna pull a gun on you, but don't be afraid. I'm silly, so. Now, I'm floating back down to the ground floor. I never realized I could fly so easily.
Dustin McLean: Now, the Rabbi's walking right behind me. I don't know why he is following me, maybe he wants this book.
[Music Playing]
[Chimpanzee Sounds]
Dustin McLean: Check out my cool new sweater. I just bought it, it's from The Gap. It was just forty dollars.
Jonah Ray: La la la la. All right. Now! Damn it! Got it, now! Come on! You're kidding me! Just catch it! All right, I'm throwing the book. Now! Yeah! Thank you!
Dustin McLean: Do you like my mullet? Business in front, party in back. Now, I'm an old man.


text:
This either means that the username and password information in your
db-config.php file is incorrect, you haven't declared a global database or we can't contact the global database server. This could mean your host's database server is down.
If you're unsure what these terms mean you should probably contact your host. If you still need help you can always visit the WordPress Support Forums.


text:
Magnetic Resonance Spectroscopy (MRS)
por Denis Hoa
Objetivos pedagógicos
After reading this chapter, you should be able:
- To set out the physical mechanisms used to differentiate metabolites according to resonance frequency
- State the material conditions and optimization required to measure a spectrum
- List the quality criteria of a spectrum
- Present the different metabolites explored in brain MRS, their position on the spectrum and their interest
- Explain the different stages to obtain a monovoxel spectrum
- Describe PRESS and STEAM sequences and the influence of TE on the spectrum
- Specify the adaptations required for spectroscopic imaging: spatial encoding, reduced acquisition time
Pontos principais
- The resonance spectrum identifies metabolites by:
- Locating the peak(s), determined by chemical shift (ppm) resulting from the shield formed by the electronic cloud of hydrogen nuclei in the molecules
- The same compound being characterized by several peaks (doublet, triplet) due to spin-spin coupling (or J coupling) phenomena: Lac (1.7 and 1.33 ppm)
- Magnetic resonance spectrometry requires a very homogeneous magnetic field (shimming), a volume voxel and a sufficient number of measurements
- Principal metabolites studied in MRS of the 1H nucleus: see tab. 15.1
- Any method of spectroscopy, calls for suppression of the water signal (CHESS), and possibly of the fat signal: present in large quantities in the body, these have a masking effect on the metabolites close to their resonance peaks.
- The basic spectroscopy sequences are PRESS and STEAM. PRESS records a spin echo whereas STEAM only records a stimulated echo, of weaker intensity. Both have an excitation pattern comprised of 3 RF pulses.
- In single voxel spectroscopy the 3 RF pulses select the voxel of interest, located at the intersection of the 3 orthogonal planes. The recorded echo comes from the voxel submitted to the 3 RF pulses only.
- In chemical shift imaging (CSI), the 3 RF pulses select a slice or volume that is spatially encoded by phase gradients. There are different methods of accelerating CSI data acquisition. Chemical shift imaging yields multiple spectra of the slice or volume of interest. These are represented as a parametric image or studied separately.
- Quantification tends to be relative, although it is possible under certain conditions, after calibration, to produce absolute quantification of the metabolite concentration.
- The fields of application of magnetic resonance spectrometry are essentially those of: tumors, inflammatory and infectious pathologies and metabolic pathologies, mainly of the brain. Numerous developments are taking place in regard to other organs (prostate, breast, bones and joints…)
- Galanaud, Nicoli. [Brain magnetic resonance spectroscopy.]. Journal de radiologie. 2007 Mar;88(3 Pt 2):483-96.
- Jansen, Backes. 1H MR spectroscopy of the brain: absolute quantification of metabolites. Radiology. 2006 Aug;240(2):318-32.
- Burtscher and Holtas. Proton MR spectroscopy in clinical routine. J Magn Reson Imaging. 2001 Apr;13(4):560-7.
- Dydak and Schar. MR spectroscopy and spectroscopic imaging: comparing 3.0 T versus 1.5 T. Neuroimaging clinics of North America. 2006 May;16(2):269-83, x.
- Mullins. MR spectroscopy: truly molecular imaging; past, present and future. Neuroimaging clinics of North America. 2006 Nov;16(4):605-18, viii.
- Kwock. Localized MR spectroscopy: basic principles. Neuroimaging clinics of North America. 1998 Nov;8(4):713-31.
- Pohmann, von Kienlin. Theoretical evaluation and comparison of fast chemical shift imaging methods. J Magn Reson. 1997 Dec;129(2):145-60.
- Bartella, Morris. Proton MR spectroscopy with choline peak as malignancy marker improves positive predictive value for breast cancer diagnosis: preliminary study. Radiology. 2006 Jun;239(3):686-92.
- Katz and Rosen. MR imaging and MR spectroscopy in prostate cancer management. Radiologic clinics of North America. 2006 Sep;44(5):723-34, viii.


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Toner Cartridges For Dell Laser 1135n
LD Products carries compatible replacement laser toner cartridges that are compatible with the Dell Multi-Function Laser 1135n. Our professionally manufactured alternative cartridges are not refurbished Dell OEM cartridges, they are Non-OEM products that have been manufactured by a manufacturer that has no affiliation with Dell*. Our low priced alternatives to Dell OEM Cartridges are manufactured to the highest performance and quality standards, and will deliver optimal prints when used in your Dell 1135n. Purchasing our compatible replacement cartridges compatible with your Dell 1135n is an excellent way to save money without sacrificing quality. LDproducts.com guarantees our Non-OEM laser toner cartridges' compatibility with your Dell 1135n with a 'Two Year 100% Quality Satisfaction Guarantee'. The use of our alternative laser toner cartridges compatible with the Dell 1135n does not void your printer's warranty. More
Dell Laser 1135n Toner
Compatible Alternative for Dell 330-9523 / 7H53W High Yield Black Laser Toner Cartridge for Dell 1130 Printers
Dell OEM 330-9523 (7H53W) High-Yield Black Laser Toner Cartridge for 1130 Printers
Original Black Toner for Dell 1130 Laser Printers (3J11D) 1,500 Page Yield
* These cartridges are not endorsed, associated with, or refilled by Dell and are low priced alternatives to Dell OEM Cartridges.