Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse [Internet]

Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. Report No.: 12-EHC055-EF.


Objectives: To assess the effectiveness of screening followed by behavioral counseling for adolescents and adults with alcohol misuse in primary care settings.

Data Sources: MEDLINE®, Embase®, the Cochrane Library, CINAHL®, PsycINFO®. Additional studies were identified from reference lists and technical experts.

Review Methods: Two people independently selected, extracted data from, and rated the quality of relevant trials and systematic reviews. Quantitative analyses were conducted for outcomes when feasible and used subgroup analyses to explore whether results differed by intensity, sex, country, person delivering the counseling, or setting. Two reviewers graded the strength of evidence (SOE).

Results: A total of 23 trials and six systematic reviews were included. The trials generally enrolled subjects with risky/hazardous drinking, usually excluding those with alcohol dependence. Among adults receiving interventions, consumption decreased by 3.6 drinks per week (weighted mean difference [WMD], 3.6, 95% confidence interval [CI], 2.4 to 4.8), 12 percent fewer subjects reported heavy drinking episodes (risk difference 0.12, 95% CI, 0.07 to 0.16), and 11 percent more subjects reported drinking beneath recommended limits (risk difference, 0.11, 95% CI, 0.08 to 0.13) over 12 months compared with controls (moderate SOE). Interventions improved some utilization outcomes (e.g., hospital days and costs: low SOE). 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). The best evidence of effectiveness is for brief (generally, 10 to 15 minutes) multicontact interventions.

For older adults, trials provided evidence of effectiveness, but effect sizes were smaller than for all adults. Trials enrolling college students provided evidence of effectiveness for reducing consumption and heavy drinking episodes (moderate SOE) and some accident, utilization, and academic outcomes (low, low, and moderate SOE, respectively). Studies in adults found benefits lasting several years; for college students, some benefits found at 6 months were no longer significantly different for intervention versus control groups at 12 months. The one study enrolling pregnant women did not find a significant difference for reduction in consumption. Evidence was insufficient for adolescent populations.

No studies randomized subjects, practices, or providers to screening and a comparator, and none of the included studies reported followup with referrals as an outcome.

Conclusions: Behavioral counseling interventions improve behavioral outcomes for adults with risky/hazardous drinking. For most health outcomes, available evidence either found no difference between interventions and controls or was insufficient to draw conclusions. The best evidence of effectiveness is for brief multicontact interventions.

Publication types

  • Review

Grant support

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Contract No.290-2007-10056-I. Prepared by: RTI International–University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC