Department of Health and Society, Division of Social Medicine and Public Health Science, Linköping University, S-581 83 Linköping, Sweden
* Author to whom correspondence should be addressed at: Department of Health and Society, Division of Social Medicine and Public Health Science, Linköping University, S-581 83 Linköping, Sweden. Tel.: +46 13 22 51 10; Fax: +46 13 22 18 65; E-mail: cecno{at}ihs.liu.se
(Received 10 November 2004; first review notified 8 March 2005; in revised form 25 April 2005; accepted 18 May 2005)
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
In recent years, various forms of relatively simple alcohol preventive interventions have been introduced under the heading brief intervention in primary health care as well as in emergency departments. Babor and Higgins-Biddle (2001) describe brief intervention as a short screening followed by education as a primary preventive measure for a large cohort of non-dependent consumers. Studies using different forms of brief intervention have consistently shown that shorter interventions, lasting a few minutes, are as effective as longer ones lasting from 20 min to several hours (Nilssen, 1991
; WHO and Brief Intervention Study Group, 1996
; McIntosh et al., 1997
; Ockene et al., 1999
; Moyer et al., 2002
). The value of written self-help material, often used as a part of brief alcohol interventions, was reviewed in a metaanalysis by Apodaca and Miller (2003)
who found that self-help materials can accomplish some reduction in the alcohol consumption of patients without a one-to-one consultation and constitutes a cost-effective intervention for the large number of risky drinkers.
The number of brief intervention studies in emergency care departments is still very small. Despite the evidence on the effectiveness of a short feedback on screening or self-help material, most studies have required considerable time from ordinary or research staff. In the studies published so far from emergency care settings, the initial screening procedure required 120 min. The follow-up intervention took 15 min to 2.5 h (Krishel, 1996; Bernstein et al., 1997
; Wright et al., 1998
; Gentilello et al., 1999
; Monti et al., 1999
; Forsberg et al., 2000
; Hungerford et al., 2000
, 2003
). Consequently, brief alcohol interventions have been difficult to implement in a real world emergency setting mostly owing to the unrealistic demands on staff (Peters et al., 1998
; Brooker et al., 1999
; Charalambous, 2002
). Thus, in order to implement a routine intervention in an emergency department, where the patient contact is short, there is a need for a simpler procedure that only requires a limited time effort from the staff (Hungerford et al., 2000
, 2003
; Charalambous, 2002
). More studies are needed to establish the minimal level of alcohol intervention necessary to accomplish a reasonable change in alcohol consumption among risky drinkers.
In 2001 we implemented a procedure with screening and simple written advice performed by ordinary staff in a Swedish emergency care department (Nordqvist et al., 2004). The procedure requires only a couple of minutes of the staff's working time. To our knowledge, only three other projects have studied screening in emergency care settings performed by ordinary staff, without extra resources, with varying results (Krishel, 1996
; Wright et al., 1998
; Brooker et al., 1999
).
The aim of this study was to evaluate whether screening without one-to-one feedback and screening with simply written advice without one-to-one feedback are sufficient to initiate a self-regulation process concerning risky drinking among emergency care patients.
![]() |
METHODS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The study population included all patients aged 1670 visiting the emergency department for an injury from 1 April, 2001 to 31 March, 2002. Patients judged by staff to be too seriously injured were excluded (Nordqvist et al., 2004). In total 1895 patients, nearly all persons in the target group, were approached. Of these, 370 declined to participate or were excluded because the questionnaire lacked complete answers to the AUDIT-C questions. Abstainers (n = 191) were also excluded. Thus, a total of 1334 patients were included in the further analysis (Fig. 1).
|
Screening instrument
The screening instrument was a 10-item pen and paper questionnaire beginning with AUDIT-C (Bush et al., 1998; Gordon et al., 2001
; Rumpf et al., 2002
) which measures the frequency and quantity of consumption and frequency of heavy episodic drinking. Then, an additional seven questions with five answering alternatives explored satisfaction with drinking habits (from totally satisfied to not satisfied at all), readiness to change drinking habits (from never considering to daily considering), actual change during the last year (from stopped to increased considerable), if the patient thought that the injury was alcohol related (from had not been drinking to yes, absolutely), attitude to being asked about drinking (from very negative to very positive), where the injury took place (town), and whether the patient agreed to a follow-up telephone interview (yes or no).
Screening procedure
After verbal informed consent, ordinary staff handed out the questionnaire in the triage room to all injury patients between 16 and 70 years of age. Patients completed the questionnaire in the waiting room and returned it to the staff, who were available to help if necessary. No one-to-one feedback on the screening result was offered. The procedure took a couple of minutes of the staffs' time and 12 min for the patient to fill out. After a screening period of 6 months, the staff started to hand out simple written advice about sensitive drinking, in addition to the screening questionnaire. The information was a brochure with recommendation not to drink >7 glasses per week for women and 10 for men (the limit for low risk). The patients were advised to spread the consumption over the week and have at least 2 days without drinking. Increased risk was set to 813 glasses per week for women and 1118 glasses for men. Still no one-to-one feedback on the screening was offered.
Follow-up procedure
Regardless of the drinking status, all patients, except abstainers, were asked after completing the screening questions, to participate in a follow-up telephone interview 6 months after the screening. Those who accepted (50% in all groups) were considered as the final study group and contacted by telephone by the first author, who has previous experiences in interviewing and by a project assistant for a period. The same questionnaire as in the initial screening was used, slightly modified. There was no attempt to try to find out if the interviewee had had any contact with an alcohol agency or received treatment elsewhere. The follow-up interview took
5 min. Lost to follow-up was recorded when the person had moved and the interviewer could not find the new telephone number or when the person was not reached by telephone after five attempts. Then the questionnaire was mailed to the patient. About 25% of these mailed questionnaires were returned and included in the study. Lost to follow-up were 65 (8%) persons in cohort A and 52 (9%) in cohort B. Of the persons reached by telephone only two denied interview. In cohort A, 81 risky drinkers (44%) and 278 non-risky drinkers (47%) were followed up and in cohort B, 40 risky drinkers (32%) and 220 non-risky drinkers (50%) (Fig. 1).
Measures
The study evaluated alcohol consumption among injury patients comparing drinking status at baseline with the status at 6 months for cohorts A (screened) and B screened and simply advised. The three AUDIT-C questions and one question about motivation to change drinking habits were included in the analysis. The instrument used, the AUDIT-C, has been found to be a useful routine screening instrument because of its simplicity (Bush, 1998; Wallace, 2001
). The rate of false positive cases has proved to be high though, when the score system is used (Bush, 1998
; Aertgeerts, 2001
; Gordon, 2001
). Therefore, we did not use the scores, but calculated the consumption by multiplying questions one and two, according to the precise values in the ranges as stipulated by Säppä et al. (1995)
as discussed in another study (Nordqvist, 2004
).
Four measures of alcohol consumption were evaluated: frequency of drinking, number of drinks on a typical day, mean weekly alcohol consumption, and frequency of heavy episodic drinking.
The patients were classified as risky or non-risky drinkers, defined as weekly volume alcohol consumption above the recommended limit and/or heavy episodic drinking. The recommended cut-off level for weekly volume consumption was set according to Rydberg et al. (1993), as
80 g for females and
110 g for males. This cut-off has been used before in Sweden (Bergman and Källmén, 2002
; Hermansson, 2002
). Heavy episodic drinking was defined as six glasses or more (one glass = 12 g alcohol) at one occasion at least once a month (Bergman et al., 1998
). The question about readiness to change alcohol consumption was assumed to be positive if the person considered a reduction at least once a month.
Statistical analysis
SPSS version 11.5 was used to compare data at screening and at 6 months follow-up. Wilcoxon's signed rank test and the MannWhitney test were used to evaluate if the changes were significant. For group comparisons, chi-squared test or the unpaired t-test was used. In the follow-up analysis, males and females were not separated owing to the small numbers in the subcohorts.
The study was approved by the Ethics Committee of Linköping University.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
At baseline, 182 (24%) of patients in cohort A were classified as risky drinkers mostly owing to heavy episodic drinking. Thus, a total of 8% of the males and 2% of the females drank more than the recommended weekly volume limit and 30% of the males and 8% of the females were engaged in heavy episodic drinking at least once a month. Readiness to change was stated by 8% of males and 2% of females. In cohort B, 125 (22%) were classified as risky drinkers. A total of 6% of the males and 5% of the females drank more than the recommended weekly volume limit. Heavy episodic drinking was seen in 30% of the males and 6% of the females. Readiness to change was stated by 7% of the males and 3% of the females.
Comparison of patients followed up with those not followed up
In the following analyses males and females are considered together owing to the relatively small number of risky drinkers among females.
There were no significant differences in cohorts A or B in any drinking variable or readiness to change at baseline between risky drinkers followed up and those who declined to participate in the follow-up or were lost to follow up. Readiness to change was stated by 19% at baseline among those followed up and 16% (NS) among those not followed up in cohort A, whereas in cohort B, 8% of those followed up and 17% (NS) of those not followed up reported readiness to change drinking habits.
Non-risky drinkers followed up also did not display any differences in any drinking variable at baseline compared with those not followed up. Readiness to change was stated by 2% among both those followed up and those not followed up in cohort A and by 2% among those followed up in cohort B compared with 4% of those not followed up.
Comparisons between the cohorts revealed that readiness to change at baseline was higher among risky consumers reached at the follow-up in cohort A, 19% compared with 8% among risky consumers reached at the follow-up in cohort B (NS). The mean weekly alcohol consumption at baseline among risky drinkers reached at the follow-up in cohort A was 92 g compared with 106 g in cohort B (NS). All other drinking variables, mean age, and sex distributions were similar at baseline among risky drinkers reached at follow-up when comparing the two cohorts.
Changes in drinking pattern among risky drinkers
Cohort A. After 6 months there was one significant change in drinking pattern among those who had been risky drinkers at baseline. The proportion of heavy episodic drinking decreased by 34%. Although half of the heavy episodic drinkers maintained such a drinking pattern, more than one-third indulged in heavy episodic drinking less often, in most cases to a level beneath the cut-off for heavy episodic drinking, whereas a few were drinking heavy episodic more often than before (Tables 1 and 2). Thus, at baseline 76 (94%) of the patients were classified as heavy episodic drinkers compared with 49 (59%) at follow-up (Table 2). Although some patients decreased their frequency of drinking, others increased. The number of drinks on a typical day increased for as many as it decreased (Table 1). Half of cohort A decreased the mean consumption, a reduction from 92 g per week at baseline to 87 g at follow-up (NS). The proportion of patients with risky weekly volume consumption remained the same, 23 (28%) compared with 21 (26%). The readiness of the patients to change their consumption decreased from 15 (19%) to 11 (14%) out of 81 patients (Table 2).
|
|
|
Cohort B. Just as among non-risky drinkers in cohort A, all alcohol consumption measures as well as readiness to change were changed significantly. Mean consumption increased from 24 to 33 g per week. In addition, 15% started to engage in heavy episodic drinking and 5% in high weekly volume consumption. Readiness to change increased from 2 to 7% (Table 3).
When considering the greater number of non-risky drinkers the net effect in the study group was an increase in the alcohol consumption.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Since most previous studies have had different designs and outcome measures, the results are not directly comparable. Our screening procedure and simple advice was simpler than the screening and intervention in most previous studies and in some cases even more simple than the control group in those few studies that had a control group. For example, the control group called standard care in a study by Longabaug et al. (2001), was assessed for 3040 min. In Forsberg et al. (2000)
the comparison group was assessed with three questionnaires in total lasting for 26 min.
Changes in drinking behaviour among risky drinkers
The main drinking behaviour among risky drinkers in our study was heavy episodic drinking comprising 30% of the male and 7% of the female eligible patients at baseline. In both cohorts, there was a significant reduction in heavy episodic drinking at follow-up (34% in cohort A and 25% in cohort B). Both fairly similar and greater reduction has been reported in some of the previous studies with more extended alcohol interventions. Also, in a number of previous studies a significant reduction in the frequency of heavy episodic drinking was seen independently of the intensity of the intervention. Thus, Longabaugh et al. (2001) reported a 12% reduction in the frequency of heavy episodic drinking among risky drinkers in both the standard care group and the brief intervention group. Other studies have reported a more pronounced reduction in heavy episodic drinking than in our study. Forsberg et al. (2000)
reported a 71% reduction in the frequency of heavy episodic drinking with no significant difference between two intervention methods: simple feedback on screening or 12.5 h extended counselling by a psychologist. Bernstein et al. (1997)
showed a reduction of 64% in the frequency of heavy episodic drinking after a brief negotiating interview lasting 20 min. Thus, the reduction in heavy episodic drinking in our study was less than in most previous studies with more extended intervention. Adding simple written advice in cohort B did not increase the effect. In fact, cohort B, who received simple written advice, displayed less reduction in the frequency of heavy episodic drinking. That could be explained by the fact that risky consumers in cohort A who were followed up, were more willing to change at baseline than the risky consumers who were followed up in cohort B.
The second drinking outcome measure in our study was the percentage of patients with weekly volume consumption above recommended limits. We did not find any significant change at the 6-month follow-up among those classified as risky drinkers at baseline. In cohort A, mean consumption decreased non-significantly by 5 to 87 g per week and decreased by 7 g in cohort B to 99 g per week. This stands in contrast to a number of previous studies on various forms of brief interventions in emergency departments where the effects on weekly consumption were reported to be significant. Thus, Gentilello et al. (1999) found a significant difference in weekly average consumption between an intervention group and a control group at a 12-month follow-up. In the study by Forsberg et al. (2000)
, weekly consumption decreased from 133 to 96 g at 6 months but increased to 106 g after 12 months in two intervention groups. Wright et al. (1998)
found a 65% reduction in average weekly volume intake after a brief intervention, from 240 to 136 g per day. Hungerford et al. (2000)
reported a reduction in alcohol consumption in 68% of 23 risky drinkers reached for a follow-up after a 1520 min counselling session and in another study, a reduction in weekly volume intake was reported in 62% of 519 risky drinkers after a similar intervention (Wright et al., 1998
; Hungerford et al., 2003
). Average weekly volume consumption was not calculated in either of Hungerford's studies. The change is based on a reduction in AUDIT scores. One explanation for the lack of change in our study is that the mean alcohol consumption was relatively low at baseline in our study groups,
90 g per week, and thus lower than in all the other studies.
The frequency of alcohol intake was the third outcome measure used in our study. Bernstein et al. (1997) found a 56% reduction in frequency of drinking after a brief negotiating interview. In our study 18% of patients in cohort B drank more often after intervention and 2% less often, whereas in cohort A, 11% drank more and 20% less frequently. Still the majority drank as often as before. Forsberg et al. (2000)
found a similar small increase in frequency of drinking. Thus, at 6-month follow-up, 32% drank more and 16% less frequently after a brief or extended intervention.
Although the numbers are low, the readiness to change increased significantly, by 15% in cohort B who received simple written advice. Most patients did not alter their readiness to change but 23% were more ready and 18% less ready to change. Cohort A seemed to have become less ready to change, 16% were more ready and 19% less ready. However, at baseline, followed up risky drinkers in cohort A were more ready to change than followed up risky drinkers in cohort B (19% compared to 8%). At the follow-up, cohort A had decreased to 14% readiness to change whereas cohort B increased to 22%. This is in contrast to Forsberg et al. (2000) who showed that 16% were more ready and 33% were less ready to change at the 6-month follow-up. In the study by Hungerford et al. (2000)
, 43% of the 23 patients at the follow-up had become more ready to change, even though 59% of the patients were already prepared at baseline to set goals to reduce or stop drinking. One explanation for cohort A being less ready to change at follow-up is that they had reduced heavy episodic drinking more than cohort B and thus, were in less need for additional change in their drinking behaviour.
Changes among non-risky drinkers
Non-risky drinkers are seldom or never followed up in brief intervention studies in emergency departments. In our study, both risky and non-risky drinkers were included in the follow-up in order to compare the effect of the screening and written advice and also to highlight some of the normal changes in alcohol habits in the population. Alcohol consumption increased significantly among low consumers in both cohorts according to all measures used, some to the level of risky drinking. The brochure with simple advice about drinking levels given to cohort B could have encouraged the non-risky drinkers in that cohort to drink more. However, this does not explain the increase in consumption among non-risky consumers in cohort A where no written advice was offered. It is possible that filling out the questionnaire showed the patients that they were low consumers according to the answering options. An additional explanation is that the increase is owing to the general increase in drinking in Sweden or the normal variation in consumption in the population (Bergman and Källmén, 2002; Leifman and Trolldal, 2002
). If so, the changes seen among the risky drinkers are even more encouraging.
Positive effects of only screening
Previous brief intervention studies in emergency care settings have used different kinds of screening and intervention measures (Krishel, 1996; Bernstein et al., 1997
; Wright et al., 1998
; Gentilello et al., 1999
; Monti et al., 1999
; Forsberg et al., 2000
; Hungerford et al., 2000
, 2003
). Screening varies from one questionnaire with no further assessment, to interview or several questionnaires with further assessment. The interventions were more extensive than in our study, often using motivational interviewing and sometimes referral to treatment elsewhere. Although our screening procedure seemed to have a somewhat less effect on heavy episodic drinking than in most previous studies, the reduction was not neglectable. The additional written advice to cohort B did not increase the effect on heavy episodic drinking but might have increased the readiness to change. Thus, our results support the self-regulating theory described by Agostinelli et al. (2004)
indicating that when people are given an opportunity to reflect on their drinking habits, a spontaneous self-monitoring process can lead to problem recognition. The positive effect of only screening without any feedback is also supported by some previous studies (Anderson and Scott, 1992
; WHO and Brief Intervention Study Group, 1996
). In the study by Anderson and Scott (1992)
, a control group offered only screening showed a marginally less reduction in alcohol consumption compared with an intervention group. Also Monti et al. (1999)
failed to show any difference in the reduction of alcohol consumption in young people, between a cohort receiving 3540 min of motivational interviewing and a cohort receiving 5 min of 'standard care'. Other studies from emergency care displayed a more mixed result. In the WHO study a control group, receiving no advice, showed no significant difference between intervention and control groups among female patients but among males, the reduction was significantly higher in the intervention group (WHO and Brief Intervention Study Group, 1996
). Gentillello et al. (1999)
showed a similar reduction in drinking after 6 months in a control group as in the intervention group. After 12 months, however, the control group drank as much as before the screening whereas the reduction in the intervention group was stable.
Whether screening per se has an effect on drinking habits is still an unanswered question that probably will be very difficult to answer. However, adding simple written advice do not add any benefit to the possible effect of screening with regards to reducing risky drinking.
Methodological considerations
We did not have a control group but evaluated the effect of screening compared with screening and simple advice. A weakness in our study is that we did not study the longer term effect of our screening and simple written advice. However, the number of patients included in the follow-up, 619 (of which 121 were risky drinkers), are a strength in our study and also that there was no difference in drinking pattern at baseline between those followed up and those declining to participate. The positive results shown in other studies are often based on a small number of follow-ups, from 12 to 87 patients (Krishel, 1996; Wright et al., 1998
; Monti et al., 1999
; Hungerford et al., 2000
) although some had higher numbers, from 165 to 519 (Forsberg et al., 2000
; Longabaugh et al., 2001
). For example Krishel et al. (1996)
showed that out of 12 followed up, 5 drank less and 1 was on treatment.
![]() |
CONCLUSIONS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
ACKNOWLEDGEMENTS |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Agostinelli, G., Floyd, T., Grube, J. et al. (2004) Alcohol problem recognition as a function of own and others' perceived drinking. Addictive Behaviours 29, 143157.[CrossRef][ISI][Medline]
Anderson, P. and Scott, E. (1992) The effect of general practitioners' advice to heavy drinking men. British Journal of Addiction 87, 891900.[ISI][Medline]
Apodaca, T. and Miller, W. (2003) A meta-analysis of the effectiveness of bibliotherapy for alcohol problems. Journal of Clinical Psychology 59, 289304.[CrossRef][ISI][Medline]
Babor, T. F. and Higgins-Biddle, J. C. (2001) Brief Intervention for Hazardous and Harmful Drinking. A Manual for Use in Primary Care. World Health Organization, Geneva.
Barnett, N., Spirito, A., Colby, S. et al. (1998) Detection of alcohol use in adolescent patients in the emergency department. Academic Emergency Medicine 5, 607612.[Abstract]
Bergman, H. and Källmén, H. (2002) Alcohol use among Swedes and a psychometric evaluation of the Alcohol Use Disorders Identification Test. Alcohol and Alcoholism 37, 245251.
Bergman, H., Källmén, H. and Rydberg, U. (1998) Tio frågor om alkohol identifierar alkoholproblem. Läkartidningen, 47314735.
Bernstein, E., Bernstein, J. and Levenson, S. (1997) Project ASSERT: an ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Annals of Emergency Medicine 30, 181189.[ISI][Medline]
Brooker, C., Peters, J., McCabe, C. et al. (1999) The views of nurses to the conduct of a randomised controlled trial of problem drinkers in an accident and emergency department. International Journal of Nursing Studies 36, 3339.[CrossRef][ISI][Medline]
Bush, K., Kivlahan, D., McDonell, M. et al. (1998) The AUDIT Alcohol Consumption Questions (AUDIT-C) an effective brief screening test for problem drinking. Archives of Internal Medicine 158, 17891795.
Charalambous, M. (2002) Alcohol and the accident and emergency department: a current review. Alcohol and Alcoholism 37, 307312.
Cherptiel, C. (1996) Regional differences in alcohol and fatal injury: a comparison of data from two coroners. Journal of Studies on Alcohol 57, 244248.[ISI][Medline]
Conigrave, K. M., Burns, F. H., Reznik, R. B. et al. (1991) Problem drinkers in emergency department patients: the scope for early intervention. The Medical Journal of Australia 154, 801805.[ISI][Medline]
Forsberg, L., Ekman, S., Halldin, J. et al. (2000) Brief interventions for risk consumption of alcohol at an emergency surgical ward. Addictive Behaviors 25, 471475.[CrossRef][ISI][Medline]
Forsberg, L., Halldin, J. and Wennberg, P. (2003) Psychometric properties and factor structure of the readiness to change questionnaire. Alcohol and Alcoholism 38, 281286.
Gentilello, L., Rivara, F., Donovan, D. et al. (1999) Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Annals of Surgery 230, 473483.[CrossRef][ISI][Medline]
Gordon, A. J., Maistro, S. A., McNeil, M. et al. (2001) Three questions can detect hazardous drinkers. Journal of Family Practice 50, 313320.[ISI][Medline]
Hadida, A., Kapor, N., Mackway-Jones, K. et al. (2001) Comparing two different methods of identifying alcohol related problems in the emergency department: a real chance to intervene? Emergency Medical Journal 18, 112115.
Hermansson, U. (2002) Risky alcohol consumption in the workplace-the feasibility of early detection and brief intervention as a part of routine health examinations. In Department of Clinical Neuroscience. Karolinska Institutet, Stockholm.
Hungerford, D. and Pollock, D. (2003) Emergency department services for patients with alcohol problems: research directions. Academic Emergency Medicine 10, 7984.
Hungerford, D., Pollock, D. and Todd, K. (2000) Acceptability of emergency department-based screening and brief intervention for alcohol problems. Academic Emergency Medicine 7, 13831392.[ISI][Medline]
Hungerford, D., Williams, J., Frurbee, P. et al. (2003) Feasibility of screening and intervention for alcohol problems among young adults in the ED. American Journal of Emergency Medicine 21, 1422.[CrossRef][ISI][Medline]
Karlsson, A. and Bendtsen, B. (2004) Acceptability of a computerized alcohol screening and advice routine in an emergency department settinga patient perspective. Addictive Behaviors 30, 767776.[CrossRef][ISI]
Krishel, S. (1996) Feasibility of routine screening of patients for alcohol abuse. Academic Emergency Medicine 3, 903905.[ISI][Medline]
Leifman, H. and Trolldal, B. (2002) Svenskens alkoholkonsumtion i början av 2000-taletmed betoning på 2001 (Swedish alcohol consumption at the beginning of the 2000s, with emphasis on 2001). Report 3. SoRAD, Stockholm.
Longabaugh, R., Woolard, R., Nirenberg, T. et al. (2001) Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department. Journal of Studies on Alcohol 62, 806816.[ISI][Medline]
Maio, R., Shope, J., Blow, F. et al. (1995) Alcohol and injury in the emergency department: opportunities for intervention. Annals of Emergency Medicine 26, 221223.[ISI][Medline]
McIntosh, M. C., Leigh, G., Baldwin, N. J. et al. (1997) Reducing alcohol consumption. Comparing three brief methods in family practice. Canadian Family Physician 43, 19591962, 19651967.[ISI][Medline]
Monti, P., Colby, S., Barnett, N. et al. (1999) Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. Journal of Consulting and Clinical Psychology 67, 989994.[CrossRef][ISI][Medline]
Moyer, A., Finney, J., Swearingen, C. et al. (2002) Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97, 279292.[CrossRef][ISI][Medline]
National Institute on Alcohol Abuse and Alcoholism (1993) Eight Special Report to the US Congress on Alcohol and Health. US Department of Health and Human Services, Rockville, MD.
Nilssen, O. (1991) The Tromso Study: identification of and a controlled intervention on a population of early-stage risk drinkers. Preventive Medicine 20, 518528.[CrossRef][ISI][Medline]
Nordqvist, C., Johansson, K. and Bendtsen, P. (2004) Routine screening for risky alcohol consumption at an emergency department using the AUDIT-C questionnaire. Drug and Alcohol Dependence 74, 7176.[CrossRef][ISI][Medline]
Ockene, J. K., Adams, A., Hurley, T. G. et al. (1999) Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers. Archives of Internal Medicine 159, 21982205.
Peters, J., Brooker, C., McCabe, C. et al. N. (1998) Problems encountered with opportunistic screening for alcohol-related problems in patients attending an Accident and Emergency department. Addiction 93, 589594.[CrossRef][ISI][Medline]
Raffle, P. (1989) Interrelation between alcohol and accidents. Journal of the Royal Society of Medicine 82, 132135.[ISI][Medline]
Roche, A., Watt, K., McClure, R. et al. (2001) Injury and alcohol: a hospital emergency department study. Drug and Alcohol Review 20, 155166.[ISI]
Romelsjö, A., Alberts, K. and Andersson, R. (1993) The Stockholm County programmes for accident and alcohol prevention and injury surveillance-initial experiences. Addiction 88, 10131016.[ISI][Medline]
Rumpf, H.-J., Hapke, U., Meyer, C. et al. (2002) Screening for alcohol use disorders and at-risk drinking in the general population: psychometric performance of three questionnaires. Alcohol and Alcoholism 37, 261268.
Rydberg, U., Thakker, K. D. and Skerfving, S. (1993) Risk evaluation of alcohol. International Review of Psychiatry 1, 563600.
Seppä, K., Mäkelä, R. and Sillanaukee, P. (1995) Effectiveness of the Alcohol Use Disorders Identification Test in Occupational Health Screenings. Alcoholism: Clinical and Experimental Research 19, 9991003.[ISI][Medline]
Wallace, P. (2001) Editorials: patients with alcohol problemssimple questions is the key to effective identification and management. British Journal of General Practice 51, 172173.[ISI][Medline]
WHO and Brief Intervention Study Group (1996) A cross-national trial of brief interventions with heavy drinkers. American Journal of Public Health 86, 948955.[Abstract]
Wright, S., Moran, L., Meyrick, M. et al. (1998) Intervention by an alcohol health worker in an accident and emergency department. Alcohol and Alcoholism 33, 651656.[Abstract]
Zink, B. and Maio, R. (1994) Alcohol use and trauma. Academic Emergency Medicine 1, 171174.[Medline]