Educational interventions for alcohol use disorders

By: Robert Patton, Kirk J. Brower, Shannon Bellefleur and Mike Crawford

Educational interventions are ubiquitous in psychiatry. They are readily available, inexpensive to deliver, and can be facilitated and disseminated by nonprofessionals. Educational interventions have long been a staple element of treatment for problems with alcohol.

They accompany many of the self-help and complex interventions used in alcohol treatment. While these interventions may be efficient from an economical point of view, they are at best only modestly effective and appear to work best among people with mild to moderate abuse. They also appear to work most effectively when combined with some additional treatment delivered by people professionally trained to deliver services. Overall didactic lectures and educational films appear to have the least benefit.

Education is inherent in most alcohol-related treatment interventions. Physician education about medication is one essential part of pharmacotherapy. Brief interventions provide educational feedback to patients about normative patterns of drinking. Twelve-step facilitation therapy involves educating patients about the disease model of alcoholism and what to expect in meetings of Alcoholics Anonymous (Nowinski et al., 1994). CBT teaches patients (1) to identify high-risk situations for relapse and (2) coping skills to prevent relapse (Kadden et al., 1995).

Educational interventions are designed to increase knowledge about alcohol in such a way as to change an individual’s attitude and behaviour. Providing information about health risks and brief advice emphasizing strategies to reduce consumption are the only interventions that have been recommended for both hazardous and harmful consumption of alcohol. While education may be usefully employed as part of more complex interventions, we consider it in this article as a ‘stand-alone’ treatment.

Psychoeducation, like psychotherapy, is designed to reduce drinking and improve psychological functioning. Unlike psychotherapy, however, it can be either self-administered (Mains & Scogin, 2003) or provided by paraprofessionals and educators who have no formal training in psychotherapy. Educational approaches may involve differing degrees of contact with an educator and as minimal as one session (Apodaca & Miller, 2003). Contact with the educator can occur in-person or by telephone, postal mail (Sobell et al., 2002), or computer. Thus, it is cost-efficient and can be used in stepped care models of treatment for alcohol use disorders (Sobell & Sobell, 2000).

General advice and information

As harmful use of alcohol often persists for a long time before any help is requested, the value of educational interventions might be considered to be optimal in this group. There is some evidence that supports this. Wallace and colleagues (1988) conducted a randomised controlled trial to compare advice (a booklet combined with general advice delivered by a family practitioner) with a no-intervention control. The results showed a significantly greater reduction in the levels of gamma-glutamyl transferase in the experimental group, a valid proxy indicator of levels of alcohol consumption. In the largest randomized trial of brief interventions for alcohol misuse conducted to date, 1661 people who were misusing alcohol but were non-dependent were recruited in primary and secondary care settings across ten countries (Babor & Grant, 1992).

One of the strengths of this study is that patients were recruited from study centres in Central America, Africa and Asia, in addition to centres in Europe and North America where most other trials of interventions for alcohol misuse have been conducted. The study compared the effects of screening plus 5 minutes of brief advice with screening plus 15 minutes of counseling and a ‘screening alone’ control arm. A follow-up rate of 73% was achieved at 9 months. The study demonstrated that 5 minutes brief advice was as effective as 15 minutes counseling. Men who received one of these two active interventions reported drinking 25% less alcohol daily compared to those who received screening alone. Among women, statistically significant differences in drinking patterns between those randomized to active and control treatments were not observed.

Findings from this and other trials involving educational intervention have subsequently been reviewed on numerous occasions (e.g. Bien et al., 1993; Mullen et al., 1997; Dunn et al., 2001). These reviews have reached similar conclusions: that brief educational interventions directed towards those drinking excessively result in reductions in alcohol consumption and that extended interventions offer little additional benefit. In their meta-analysis of 34 trials in non-treatment seeking populations, Moyer and colleagues (2002) highlighted a trend towards brief interventions having less impact among people with more severe alcohol-related problems. Few trials have followed up people beyond 12 months and those that have suggest that benefits associated with brief educational interventions do not persist beyond this period.

Educational interventions are popular in the US. For example, they are commonly used for remediation of drunk driver offenders. Alcoholics Anonymous and other mutual help groups, such as Rational Recovery and Moderation Management, publish books and pamphlets as well as maintain websites (Finfgeld, 2000b). Indeed, most mainstream bookstores in the USA have moderately sized sections devoted to self-help and recovery books (Finfgeld, 2000a). Surveys of internet-based and mail-delivered educational interventions indicate a high degree
of acceptance by users (Kypri et al., 2005).

Bibliotherapy

Bibliotherapy has been defined as the use of self-help materials or ‘‘any therapeutic intervention that was presented in a written format, designed to be read and implemented by the client’’ (Apodaca & Miller, 2003). More simply, bibliotherapy refers to ‘‘the therapeutic use of written materials to effect behavioral change’’ (Walitzer & O’Connors, 1999). Examples of bibliotherapy include the Big Book of Alcoholics Anonymous (A. A., 2001), which is also available on-line, and a variety of behavioural self-control training books (e.g. Sanchez-Craig, 1993). New information, however, can also be learned by listening to lectures, watching movies (Davis et al., 2002), and utilizing computer-assisted formats (Hester & Delaney, 1997), including accessing websites (Cunningham et al., 2005; Walters et al., 2005). Obviously, psychoeducation refers to a broad category of heterogeneous interventions.

Bibliotherapy for alcohol misuse was originally developed as an adjunct to psychological treatments (Miller 1978; WHO, 1996). Cunningham and colleagues (2001) used a quasi-experimental design to evaluate the impact of supplementing routine care for people attending an alcohol treatment centre with a booklet providing advice and information aimed at people who want to reduce the amount they drink. Over a 6-month period, half of those attending the centre were provided with the booklet. Follow-up data on a subset of these patients demonstrated that people who received a booklet were drinking 1.4 fewer drinks per day than those who received standard care alone.

Apodaca & Miller (2003) conducted a meta-analysis of 22 randomized trials on the effectiveness of bibliotherapy for problem drinking. All studies involved the distribution of self-help reading materials by healthcare professionals, even when there was no direct contact with the professional. Studies involving more than one face-to-face session with a professional were excluded. Overall, the conclusion was that bibliotherapy compared to no treatment has a small beneficial effect (weighted mean effect size ¼ 0.31). But there were other conclusions from the meta-analysis as well. First, while bibliotherapy is more effective than no treatment, it is not more effective than extensive interventions. Second, bibliotherapy is more effective for self-referred drinkers (pre/post within-group effect size of 11 studies ¼ 0.80) than those identified through opportunistic screening in medical practice (pre/post within-group effect size of 8 studies ¼ 0.65).

The most likely explanation is that self-referred drinkers are more motivated to reduce drinking than those referred for education after opportunistic screening. Third, self-help materials that included specific behavioral strategies (such as setting drinking goals, monitoring drinking habits, and solving problems without alcohol) are more effective than those containing general information and advice to reduce drinking only. As summarized by one group of investigators, specific advice is more effective than non-specific advice (Spivak et al., 1994). Finally, bibliotherapy is best studied and recommended for at-risk and problem drinkers and not for patients with severe alcohol dependence. Consistent with these conclusions, a newer study, in which emergency care patients received either screening alone or screening plus simple written advice about sensible drinking limits, showed no added effect of bibliotherapy on drinking consumption (Nordqvist et al., 2005).

Other educational interventions

School-based education efforts for public and college students

Studies which have aimed to examine the impact of public education campaigns have generally reported no impact on levels of alcohol consumption (Raistrick et al., 1999). Such campaigns may have modest effects on improving knowledge about alcohol but have not been demonstrated to lead to a change in behavior. Somewhat better results have been demonstrated with school-based educational programs in which information about alcohol is usually provided in the context of general information on alcohol and other drugs (White & Pitts, 1998; Botvin et al., 1995). Observational studies of school-based education on alcohol have demonstrated lower levels of alcohol misuse (Dielman, 1995). More recently randomized trials of school-based educational interventions aimed at preventing alcohol and drug misuse have demonstrated changes in attitudes to alcohol but little impact on actual patterns of consumption (Palinkas et al., 1996; Lindberg et al., 2002). A quasi-randomized study was conducted among secondary school students in Perth, Western Australia by McBride and colleagues (2004). In this study students were provided with an intervention aimed at minimizing harm associated with excessive alcohol consumption. Teaching was combined with skills training and use of videos and workbooks and was delivered over a 2-year period. Over 1700 (76%) of the original sample were followed up over a 32-month period. In addition to changes in knowledge and attitudes to alcohol, students who received this teaching reported consuming 31% less alcohol than those who did not. Seventeen months after delivery of the intervention, students who received training continued to drink less than those who did not, but differences between groups were no longer statistically significant.

A targeted group for educational approaches has been college students for whom the goal is to reduce at-risk and problem drinking. In general, educational programs which only provide information in the absence of motivational or skills-building strategies are not effective (Larimer & Cronce, 2002). Research with college students indicates that they have a tendency to misperceive norms about drinking patterns among their peers. For example, college students typically overestimate how much other students drink. Personalized feedback comparing a student’s own drinking patterns to those of age- and sex-matched peers is referred to as normative education (Walters & Neighbors, 2005). In one study of normative education, heavy-drinking college students were randomized to receive by mail either (1) a two-page information form comparing their drinking to normative drinking patterns of their peers with advice to reduce drinking, or (2) an educational brochure about alcohol use with advice to reduce drinking (Collins et al., 2002). The first group had significantly fewer heavy drinking episodes at the 6-week follow-up assessment when compared to the second group, suggesting that education involving personalized feedback about drinking was more effective than general information about drinking. Similar outcomes were obtained when normative education was delivered by computer (Neighbors et al., 2004). Findings from studies among young people set outside of educational establishments have generated less positive findings. A recent systematic review concluded that there is insufficient information to support claims that they are effective (Gates et al., 2006).

Other groups and other interventions

Education has long been a mainstay intervention for convicted drunk drivers. When compared to other remedial interventions for preventing repeat drunk-driver offences, education in combination with psychotherapy was more effective than education alone, which was more effective than probation alone (Wells-Parker et al., 1995). The first randomized controlled trial comparing education alone to education plus exposure to a victim impact panel demonstrated no advantage of the victim impact panel (Polacsek et al., 2001).

Psychoeducation for alcohol use disorders has been used as a control group in randomized controlled trials, implying that it is either an inactive or minimal intervention; yet results are mixed. For example, group psychoeducation performed as well as CBT in improving alcohol outcomes in 88 adolescents with mixed diagnoses of alcohol abuse or dependence and/or marijuana abuse or dependence (Kaminer et al., 2002). On the other hand, it was inferior to standard outpatient alcoholism treatment for the outcome of abstinence in a study of male alcoholic veterans (Davis et al., 2002). The latter study, however, did not control for treatment intensity and it selected for dependent drinkers.

Strengthening Families Program (SFP)

The Strengthening Families Program was designed to reduce adolescent substance misuse by increasing parenting skills and helping young people to develop their confidence and life skills (Kumpfer et al., 1996). The intervention involves parents and young people meeting separately and together in interactive groups with use of educational materials, themed discussions and role-play. In a systematic review of educational programs to prevent alcohol misuse among young people (aged 25 and under), Foxcroft et al. (2003) concluded that the SFP showed promise as an effective prevention initiative, with a number needed to treat (NNT) of 9.

Internet and computer-based education

Currently, evidence to support internet-based approaches is only beginning to accumulate (Cunningham et al., 2005; Walters et al., 2005). Although the medium is relatively novel, the educational components such as individualized and normative feedback remain similar to those delivered by other formats. The ease of accessibility may give the internet an advantage; however, the quality of information is not regulated.

Both internet and computer-based education are likely to be of value in some form as a means of reducing alcohol misuse. Joinson & Banyard (2003) present limited evidence that drinkers who are contemplating reducing their alcohol consumption are less likely to access related information of the internet compared to those who are at a pre-contemplative stage. Reis et al. (2000) presented data from an uncontrolled study of 4695 students in an evaluation of a CD-ROM aimed at preventing alcohol-related harm. Although the absence of a control group inhibits interpretation of study findings, there were suggestions of improvements in knowledge among participants.

Educational lectures and films

Miller et al. (1998) reviewed 31 studies of educational lectures and films and found that only 4 demonstrated a positive outcome. In the most recent review of alcohol treatment modalities, Miller & Wilbourne (2002) rated educational lectures, films and groups as one of the least effective approaches for reducing alcohol misuse.

Summary

There is a strong evidence base to recommend educational intervention for all patients including at-risk, problem, and dependent drinkers. Nevertheless, it is only moderately effective and appears most effective with people who have mild to moderate problems with alcohol. Education can be enhanced significantly by combining it with motivational techniques, skills training, and psychotherapy since education as a stand-alone intervention is generally less effective than when combined with other strategies.

In the UK, the importance of educational interventions is reflected in official guidelines from the World Health Organization (WHO, 2004) and in national guidelines (e.g. UK Alcohol Forum, 2001; Scottish Intercollegiate Guidelines Network, 2003), which endorse these approaches as part of first-line treatment for helping people who misuse alcohol. Self-help manuals linked to brief advice are generally recommended as second-line treatment in official guidelines (Scottish Intercollegiate Guidelines Network, 2003). The impact of other forms of educational information is less certain.

References

Peter Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in Psychiatry, Cambridge University Press 2008.

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