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

SECTION ELEVEN: CONCLUSIONS AND RECOMMENDATIONS

INTRODUCTION

11.1 This report has reviewed additional evidence on the effectiveness and cost-effectiveness of interventions aimed at reducing alcohol misuse. In this section, the main findings are summarised, with particular emphasis on evidence that confirms previous conclusions or is additional. The implementation issues and recommendations from the previous report are then considered in terms of any changes that follow from the additional evidence reviewed.

REVIEW CONCLUSIONS

Summary of available evidence

Effectiveness

11.2 The main findings relating to interventions that are supported by the evidence base are summarised in table 11.1. 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);

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

11.3 There is evidence that legislative interventions to reduce permitted blood alcohol levels for drivers, to raise the legal drinking age and to control outlet density have been effective but this evidence relates mainly to the US. There is no certainty that the results would transfer to the UK, where there is a different cultural attitude towards alcohol. Evidence from the US and Australia supports the effectiveness of random breath testing of drivers but similar arguments may apply. There is no clear evidence of effectiveness relating to prevention of alcohol misuse, mainly because of the weaknesses of the research carried out. Some effects on knowledge and attitudes have been found but none relating to drinking behaviour. There is some evidence that community action may reduce drink related problems.

Cost-effectiveness

11.4 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.

11.5 None of the costs were taken from UK settings but the results for brief interventions and for Acamprosate have been confirmed using UK cost data. More recently, the cost-effectiveness of psychosocial interventions, Acamprosate and Naltrexone have been modelled for Scotland. In general, regardless of the country setting, home treatment and outpatient treatment are likely to be cost-effective alternatives to inpatient treatment provided that they are at least as effective. The only UK cost-effectiveness result related to the relative cost-effectiveness of specialist workers in screening for alcohol misuse in a general hospital setting. The cost-effectiveness of random breath testing and server training programmes depends upon the cost-offsets achieved, and these may be lower in the UK than in the US settings in which these studies took place. One Australian study has shown that thiamine supplementation of full strength beer is cost-effective in the prevention of Wernicke-Korsakoff syndrome.

General issues

11.6 Interventions that do not appear in table 11.1 are not necessarily ineffective but no strong evidence to support them has been found in the review. The size and strength of the evidence base is very variable but it is apparent that interventions are required across all areas. The different types of intervention are not substitutes for each other but tackle different aspects of the alcohol misuse problem. There is much less evidence about cost-effectiveness than effectiveness.

11.7 The update of the previous review has identified a reasonable number of additional studies but the majority of these have confirmed previous findings rather than presenting new information. The extent and quality of the research continues to vary between types of intervention. Treatment interventions have been subject to the most rigorous evaluations and the literature contains a number of meta-analyses of well-conducted randomised controlled trials. There is a large volume of research in the area of prevention but the study designs and the resulting evidence are weak. Policy interventions and the effects of legislation and enforcement have been less well researched.

11.8 The volume of cost-effectiveness literature is much smaller and is strongest in the areas of brief interventions and relapse prevention. A weakness of this area is that most studies have not been conducted alongside effectiveness studies but have modelled results based on values obtained from the literature. Few studies have addressed the health benefits of interventions with the result that outcomes in terms of cost per life year are rarely produced in the literature.

Main gaps in the evidence base

11.9 The gaps in the evidence base that were reported in the previous review have been updated within each section. There remains a particular lack of sound evidence, applicable to the UK, in the area of policy, legislation and enforcement. More attention requires to be given to evaluating alcohol initiatives in the UK and these evaluations should be planned at an early stage in the development of an initiative. Despite a plethora of research, the evidence relating to prevention is weak and better research designs are required. In screening and treatment, there is a sound basis of evidence for a number of interventions but additional research would be beneficial. In all areas, there is a need for better economic studies.

IMPLEMENTATION ISSUES

11.10 The previous report argued that the results of the evidence review should be interpreted alongside information about interventions that are already taking place. Both the impact which interventions will have upon strategic targets and the resources required to implement interventions will depend upon the extent to which they have already been deployed. It should also be noted that the effectiveness of these interventions has been demonstrated in research settings and requires to be confirmed in routine practice. Arrangements for auditing or monitoring the effectiveness of interventions will need to be put in place.

RECOMMENDATIONS

11.11 On the basis of the evidence reviewed previously, the following recommendations were made:

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

• the development of monitoring arrangements to assess the impact of these interventions at the national level;

• improved access to treatment and relapse prevention; and

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

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.

Research Strategy

11.12 The previous report drew attention to the need for a more focussed use of research capacity and more accessible results and made the following specific recommendations:

• 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.

Table 11.1 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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