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EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL MISUSE IN SCOTLAND: AN UPDATE TO THE LITERATURE REVIEW

EXECUTIVE SUMMARY

AIM OF THE STUDY

0.1 The aim of this study is to update the review of evidence on the effectiveness and cost-effectiveness of interventions aimed at reducing alcohol misuse, published in 2002, and to identify any new findings in this literature.

METHODS

0.2 As in the original review, this update is based on reviews of effectiveness and individual economic evaluation studies. This reflects the relative size of the two types of literature. The search strategies and databases used replicated the searches carried out for the original review. (See Ludbrook et al 2002 pp11-12 and pp15-16). Databases were searched from 2000 in order to overlap the period of the previous review.

0.3 The quality of the effectiveness reviews and the economic evaluation studies was assessed using the same criteria as the original review (see Ludbrook et al p12 and p16). All economic evaluations have been included, even if they are incomplete in their coverage of costs or benefits. As with the previous review, there are very few good quality economic evaluations.

EFFECTIVENESS REVIEW - MAIN FINDINGS

0.4 There are seven broad categories of interventions. Most of the studies reviewed for this update confirmed previous findings, with few new areas covered. The main findings are summarised below by type of intervention.

Policy and legislative interventions

0.5 There is additional evidence that fiscal policy (taxation) is effective in reducing total alcohol consumption and alcohol related problems. The variation in effect size may reflect the impact of other barriers to access; i.e. price increases have more impact where other restrictions on the availability of alcohol are fewest. Although previous evidence suggested that the alcohol consumption of the heaviest drinkers was not responsive to price increases, other studies show reductions in alcohol related problems for this group. The evidence relating to under-age and youth drinking was reported previously to be unclear but studies may have failed to take account of the true prices faced by these groups.

0.6 The effectiveness of legislation to reduce drink driving through lower permitted blood alcohol levels for younger drivers and inexperienced drivers and reductions in permitted alcohol levels for all drivers is confirmed by more recent reviews.

0.7 Evidence relating to licensing controls remains mixed. There is further evidence from the US that raising the legal drinking age to 21 has reduced alcohol related crashes and injuries and may reduce consumption. However, these results may not transfer to a UK setting because of different attitudes to drinking amongst young people in the UK.

0.8 There is still no clear evidence relating advertising and alcohol consumption. Advertising content may shape attitudes to alcohol, particularly for young people and studies are considering the effect of new approaches, such as Internet marketing.

Enforcement

0.9 There is additional evidence to support the effectiveness of random breath testing and selective breath testing. Small studies have found server training to be effective but most of the studies involve volunteer participants.

Prevention

0.10 There is still little evidence that school-based interventions have lasting effects on behaviour. Interactive delivery, parental or community involvement and peer involvement are more likely to be successful. Most studies relate to substance abuse prevention rather than alcohol alone.

0.11 One review suggests some effect on behaviour for mass media campaigns targeted at youth. Community prevention programmes are generally effective but may be focussed on drink-related problems rather than alcohol consumption. Warning labels have had little effect on behaviour in the US.

Screening and detection

0.12 One review confirms the effectiveness of AUDIT as a screening tool. One small study has evaluated a short screening method for use in A&E departments.

Brief interventions

0.13 There is additional support for the effectiveness of brief interventions. One study shows the effects being sustained over 4 years; a second study shows no difference by 10 years due to a reduction in drinking by controls.

Detoxification

0.14 No additional studies were identified.

Relapse prevention

0.15 More recent reviews continue to show the effectiveness of psychosocial interventions and pharmacological treatments as adjuncts to psychosocial interventions. No difference in effectiveness for different psychosocial interventions has been demonstrated. Direct comparisons of Naltrexone and Acamprosate are difficult as studies have different target outcomes and lengths of follow up.

COST-EFFECTIVENESS REVIEW - MAIN FINDINGS

Policy and legislative interventions

0.16 One US study modelling the effect of lower blood alcohol levels for young and inexperienced drivers shows a benefit:cost ratio of 11:1.

Enforcement

0.17 Additional studies confirm that community sobriety checkpoints using random breath testing or selective breath testing are cost-effective. Studies are from the US, Australia and The Netherlands and all show benefits in excess of costs; the smallest ratio of benefit to cost is from The Netherlands.

Prevention

0.18 Family focussed adolescent substance-use prevention programmes have been shown to be cost-effective in the US. Benefit:cost ratios for two programmes were 9.6:1 and 5.85:1

Screening and detection

0.19 One UK study estimated the cost of FAST screening in an A&E department to be £1,669 per annum for 50,000 patients.

Brief interventions

0.20 Further economic studies show brief interventions to be relatively cost-effective. At 4 years, the benefit:cost ration in Project TrEAT was 39:1. Other studies have demonstrated net resource savings. One study that did not rely on volunteer clinics or clinicians to form the intervention and control groups has found no significant difference in resource use.

Detoxification

0.21 One study of 4 centres in France provides information on costs and outcomes; the highest cost centre was also the most effective but these results need to be interpreted with caution.

Relapse prevention

0.22 Further studies have modelled the cost-effectiveness of Acamprosate. A US study demonstrated a reduction in costs from integrating general medical care with substance abuse treatment for patients with substance abuse related medical conditions. A number of US studies have compared inpatient and day patient care but for substance abuse in general and the results may not be relevant to alcohol misuse. Modelling of results for Scotland shows net savings for psychosocial interventions and for Acamprosate as an adjunct. Naltrexone had higher costs, on average, but wide confidence intervals mean that this result was not significantly different from the result for Acamprosate.

Other issues

0.23 Cross cutting reviews have looked at drinking contexts and environment for teenagers and barriers to care for women.

CONCLUSIONS

Summary of available evidence

0.24 The main findings from the review of the literature on effectiveness and cost-effectiveness are summarised in table 0.1. In terms of the effectiveness review, there is a strong and relevant evidence base to show that:

• the use of price increases, via taxation, and brief interventions will reduce the number of problem drinkers;

• effective screening tools to detect problem drinkers are available (CAGE and AUDIT); and

• detoxification services and relapse prevention, through appropriate psychosocial and pharmacological treatments, are effective.

0.25 The cost-effectiveness review found evidence to support the cost-effectiveness of:

• brief interventions;

• home and outpatient detoxification;

• outpatient treatment for relapse prevention; and

• the use of psychosocial interventions and Acamprosate as an adjunct treatment in relapse prevention.

Quality, coverage and relevance of the evidence

0.26 The quality of the effectiveness reviews and the underlying primary studies is variable. The evidence base of economic studies is weak. The best evidence of effectiveness, in terms of both quality and coverage, relates to brief interventions and relapse prevention. There are a number of economic studies in these areas, of reasonable quality, but of limited relevance to the UK. Prevention, particularly in schools, has been widely researched but the poor quality of many of the studies means that the evidence base remains weak. Policy evaluation is not of high quality and particularly difficult to relate to the UK.

RECOMMENDATIONS

0.27 The previous report made the following recommendations:

Population measures

• the introduction of a brief intervention programme where this is not already provided; and

• the development of monitoring arrangements to assess the impact of these interventions.

Treatment measures

• improved access to treatment and relapse prevention; and

• the use of cost-effective alternatives, such as home detoxification, where appropriate.

Research measures

• the prioritisation of policy evaluation and prevention as the areas requiring most development of the evidence base;

• better co-ordination of research effort with resources concentrated on fewer larger studies with longer term follow up;

• better knowledge management in terms of access to relevant research results;

• the fostering of an evaluation culture amongst those responsible for delivering services, focussed on outcomes and the monitoring of effectiveness; and

• guidelines for evaluation to assist in this process.

These recommendations are unchanged as a result of the update to the review. In addition, it is recommended that:

• more detailed consideration be given to the evidence relating to community action and the potential for community based programmes to prevent alcohol related problems.

Table 0.1 Summary of Findings

Note: Results from previous review confirmed by additional evidence appear in bold type. Results from previous review for which no additional information was found appear in plain type. New information appears in italics.

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