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Figure 1.
Analytic Framework: Screening and Interventions to Reduce Unhealthy Alcohol Use
Analytic Framework: Screening and Interventions to Reduce Unhealthy Alcohol Use

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address to allow the USPSTF to evaluate the effectiveness and safety of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. A dashed line depicts a health outcome that follows an intermediate outcome. Refer to the USPSTF Procedure Manual for further details.7

Figure 2.
Literature Search Flow Diagram: Screening and Interventions to Reduce Unhealthy Alcohol Use
Literature Search Flow Diagram: Screening and Interventions to Reduce Unhealthy Alcohol Use

Articles could appear in more than 1 key question (KQ). Reasons for exclusion: Aim: Study aim was not relevant. Setting: Study was not conducted in a country relevant to United States practice or not conducted in, recruited from, or feasible for primary care or a health system. Outcomes: Study did not have relevant outcomes or had incomplete outcomes. Population: Study was not conducted in an included population. Intervention: Intervention was out of scope. Comparator: Study did not have a comparison group. Screener: Study did not use an included screener. Design: Study did not use an included design. Quality: Study was poor quality. KQ indicates key question; USPSTF, United States Preventive Services Task Force.

Figure 3.
Test Accuracy of 1- and 2-Item Screening Tests at the Optimal Cutoff to Detect Unhealthy Alcohol Use
Test Accuracy of 1- and 2-Item Screening Tests at the Optimal Cutoff to Detect Unhealthy Alcohol Use

NR indicates not reported.

a4+ drinks includes modified 3-Item Alcohol Use Disorders Identification Test (AUDIT-3; lower threshold for females and older adults) and the Substance Use Brief Screen (SUBS). 6+ drinks includes AUDIT-3. Quant × freq includes the first 2 items from the AUDIT (range, 0-8). Maximum drinks asks “During the last 12 months, what was the LARGEST number of drinks that you drank in a single day?” 6+, 5/4+, and 4+ drinks are variations of a screening test that quantifies the number of occasions per year on which a certain amount of drinks (4-6, depending on the test) were consumed in 1 day.

bScreened group: all participants.

cStudy enrolled male participants only.

dFemale participants.

eMale participants.

fScreened group: participants aged 65 and older.

Figure 4.
Drinks per Week (Key Question 4a), Mean Difference in Change Between Alcohol Counseling Interventions and Control Groups, by Population
Drinks per Week (Key Question 4a), Mean Difference in Change Between Alcohol Counseling Interventions and Control Groups, by Population

Weights are from random-effects analysis.

Figure 5.
Subgroup and Sensitivity Analysis Results for Drinks per Week (Key Question 4a), Mean Difference in Change Between Alcohol Counseling Interventions and Control Groups, by Indicated Subgroup of Trials
Subgroup and Sensitivity Analysis Results for Drinks per Week (Key Question 4a), Mean Difference in Change Between Alcohol Counseling Interventions and Control Groups, by Indicated Subgroup of Trials

Weights are from random-effects analysis.

Table 1.  
Summary Population Characteristics for Key Question 2
Summary Population Characteristics for Key Question 2
Table 2.  
Summary Intervention Characteristics for Key Questions 4 and 5 (All Intervention Conditions)
Summary Intervention Characteristics for Key Questions 4 and 5 (All Intervention Conditions)
Table 3.  
Summary of Meta-analysis Results, Primary Drinking Outcomes for Key Question 4a
Summary of Meta-analysis Results, Primary Drinking Outcomes for Key Question 4a
Table 4.  
Summary of Evidence
Summary of Evidence
Supplement.

eMethods. Literature Search Strategies for Primary Literature

eTable 1. Inclusion and Exclusion Criteria

eTable 2. Quality Assessment Criteria

eTable 3. Summary Study Population Characteristics for Key Questions 4 and 5

eTable 4. Positive and Negative Predictive Values for a Range of Sensitivity and Specificity Based on US Prevalence of Unhealthy Alcohol Use

eTable 5. Study and Population Characteristics for Key Question 2, By Population

eFigure 1. Test Accuracy of the AUDIT-C at the Optimal Cutoff to Detect Unhealthy Alcohol Use

eFigure 2. Test Accuracy of the AUDIT-C at Cutoff of ≥3 to Detect Unhealthy Alcohol Use Among Females

eFigure 3. Test Accuracy of the AUDIT-C at Cutoff of ≥4 to Detect Unhealthy Alcohol Use Among Males

eFigure 4. Unhealthy Use, AUDIT, Cutoff ≥8, Adolescents, Young Adults, Adults, Older Adults

eFigure 5. Test Accuracy of the AUDIT to Detect the Full Spectrum of Unhealthy Alcohol Use or Alcohol Use Disorder, at Cutoffs of ≥3, 4, or 5, in US Primary Care

eFigure 6. Funnel Plot of Between-Group Difference in Change From Baseline in Drinks per Week by its Standard Error (Key Question 4a)

eFigure 7. Forest Plot of Odds Ratios for Exceeding Recommended Limits (Key Question 4a), Comparing Alcohol Counseling Interventions and Control Groups, by Population

eFigure 8. Forest Plot of Odds Ratios for Reporting a Heavy Use Episode (Key Question 4a), Comparing Alcohol Counseling Interventions and Control Groups, by Population

eFigure 9. Forest Plot of Odds Ratios for Reporting Abstinence During Pregnancy (Key Question 4a), Comparing Alcohol Counseling Interventions and Control Groups, Among Trials in Pregnant Women

eFigure 10. Forest Plot of Odds Ratios for Mortality (Key Question 4b), Comparing Alcohol Counseling Interventions and Control Groups, by Population

eReferences

1.
Mokdad  AH, Marks  JS, Stroup  DF, Gerberding  JL.  Actual causes of death in the United States, 2000.  JAMA. 2004;291(10):1238-1245. doi:10.1001/jama.291.10.1238PubMedGoogle ScholarCrossref
2.
Stahre  M, Roeber  J, Kanny  D, Brewer  RD, Zhang  X.  Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States.  Prev Chronic Dis. 2014;11:E109. doi:10.5888/pcd11.130293PubMedGoogle ScholarCrossref
3.
Center for Behavioral Health Statistics and Quality. Results from the 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf. 2017. Accessed October 2, 2017.
4.
Rehm  J, Gmel  GE  Sr, Gmel  G,  et al.  The relationship between different dimensions of alcohol use and the burden of disease—an update.  Addiction. 2017;112(6):968-1001. doi:10.1111/add.13757PubMedGoogle ScholarCrossref
5.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Harmful Interactions: Mixing Alcohol With Medicines. NIAAA website. https://pubs.niaaa.nih.gov/publications/Medicine/Harmful_Interactions.pdf. Published 2014. Accessed August 2, 2018.
6.
Moyer  VA; Preventive Services Task Force.  Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement.  Ann Intern Med. 2013;159(3):210-218.PubMedGoogle Scholar
7.
U.S. Preventive Services Task Force.  U.S. Preventive Services Task Force Procedure Manual. Rockville, MD: Agency for Healthcare Research and Quality; 2015.
8.
United Nations Development Programme (UNDP). Human Development Report 2015: Work for Human Development. UNDP website. http://hdr.undp.org/sites/default/files/2015_human_development_report_1.pdf. Published 2015. Accessed January, 2016.
9.
Whiting  PF, Rutjes  AW, Westwood  ME,  et al; QUADAS-2 Group.  QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies.  Ann Intern Med. 2011;155(8):529-536. doi:10.7326/0003-4819-155-8-201110180-00009PubMedGoogle ScholarCrossref
10.
DerSimonian  R, Kacker  R.  Random-effects model for meta-analysis of clinical trials: an update.  Contemp Clin Trials. 2007;28(2):105-114. doi:10.1016/j.cct.2006.04.004PubMedGoogle ScholarCrossref
11.
Egger  M, Davey Smith  G, Schneider  M, Minder  C.  Bias in meta-analysis detected by a simple, graphical test.  BMJ. 1997;315(7109):629-634. doi:10.1136/bmj.315.7109.629PubMedGoogle ScholarCrossref
12.
Aalto  M, Alho  H, Halme  JT, Seppä  K.  AUDIT and its abbreviated versions in detecting heavy and binge drinking in a general population survey.  Drug Alcohol Depend. 2009;103(1-2):25-29. doi:10.1016/j.drugalcdep.2009.02.013PubMedGoogle ScholarCrossref
13.
Aalto  M, Alho  H, Halme  JT, Seppä  K.  The Alcohol Use Disorders Identification Test (AUDIT) and its derivatives in screening for heavy drinking among the elderly.  Int J Geriatr Psychiatry. 2011;26(9):881-885. doi:10.1002/gps.2498PubMedGoogle ScholarCrossref
14.
Aertgeerts  B, Buntinx  F, Bande-Knops  J,  et al.  The value of CAGE, CUGE, and AUDIT in screening for alcohol abuse and dependence among college freshmen.  Alcohol Clin Exp Res. 2000;24(1):53-57. doi:10.1111/j.1530-0277.2000.tb04553.xPubMedGoogle ScholarCrossref
15.
Bartoli  F, Crocamo  C, Biagi  E,  et al.  Clinical utility of a single-item test for DSM-5 alcohol use disorder among outpatients with anxiety and depressive disorders.  Drug Alcohol Depend. 2016;165:283-287. doi:10.1016/j.drugalcdep.2016.06.003PubMedGoogle ScholarCrossref
16.
Boschloo  L, Vogelzangs  N, Smit  JH,  et al.  The performance of the Alcohol Use Disorder Identification Test (AUDIT) in detecting alcohol abuse and dependence in a population of depressed or anxious persons.  J Affect Disord. 2010;126(3):441-446. doi:10.1016/j.jad.2010.04.019PubMedGoogle ScholarCrossref
17.
Bradley  KA, Bush  KR, Epler  AJ,  et al.  Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population.  Arch Intern Med. 2003;163(7):821-829. doi:10.1001/archinte.163.7.821PubMedGoogle ScholarCrossref
18.
Buchsbaum  DG, Welsh  J, Buchanan  RG, Elswick  RK  Jr.  Screening for drinking problems by patient self-report: even “safe” levels may indicate a problem.  Arch Intern Med. 1995;155(1):104-108. doi:10.1001/archinte.1995.00430010112015PubMedGoogle ScholarCrossref
19.
Bull  LB, Kvigne  VL, Leonardson  GR, Lacina  L, Welty  TK.  Validation of a self-administered questionnaire to screen for prenatal alcohol use in Northern Plains Indian women.  Am J Prev Med. 1999;16(3):240-243. doi:10.1016/S0749-3797(98)00158-5PubMedGoogle ScholarCrossref
20.
Chung  T, Smith  GT, Donovan  JE,  et al.  Drinking frequency as a brief screen for adolescent alcohol problems.  Pediatrics. 2012;129(2):205-212. doi:10.1542/peds.2011-1828PubMedGoogle ScholarCrossref
21.
Clark  DB, Martin  CS, Chung  T,  et al.  Screening for underage drinking and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition alcohol use disorder in rural primary care practice.  J Pediatr. 2016;173:214-220.Google Scholar
22.
Clements  R.  A critical evaluation of several alcohol screening instruments using the CIDI-SAM as a criterion measure.  Alcohol Clin Exp Res. 1998;22(5):985-993. doi:10.1111/j.1530-0277.1998.tb03693.xPubMedGoogle ScholarCrossref
23.
Cook  RL, Chung  T, Kelly  TM, Clark  DB.  Alcohol screening in young persons attending a sexually transmitted disease clinic: comparison of AUDIT, CRAFFT, and CAGE instruments.  J Gen Intern Med. 2005;20(1):1-6. doi:10.1111/j.1525-1497.2005.40052.xPubMedGoogle ScholarCrossref
24.
Crawford  EF, Fulton  JJ, Swinkels  CM, Beckham  JC, Calhoun  PS; VA Mid-Atlantic MIRECC OEF/OIF Registry Workgroup.  Diagnostic efficiency of the AUDIT-C in U.S. veterans with military service since September 11, 2001.  Drug Alcohol Depend. 2013;132(1-2):101-106. doi:10.1016/j.drugalcdep.2013.01.012PubMedGoogle ScholarCrossref
25.
D’Amico  EJ, Parast  L, Meredith  LS, Ewing  BA, Shadel  WG, Stein  BD.  Screening in primary care: what is the best way to identify at-risk youth for substance use?  Pediatrics. 2016;138(6):e20161717. doi:10.1542/peds.2016-1717PubMedGoogle ScholarCrossref
26.
Dawson  DA, Grant  BF, Stinson  FS, Zhou  Y.  Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population.  Alcohol Clin Exp Res. 2005;29(5):844-854. doi:10.1097/01.ALC.0000164374.32229.A2PubMedGoogle ScholarCrossref
27.
Dawson  DA, Smith  SM, Saha  TD, Rubinsky  AD, Grant  BF.  Comparative performance of the AUDIT-C in screening for DSM-IV and DSM-5 alcohol use disorders.  Drug Alcohol Depend. 2012;126(3):384-388. doi:10.1016/j.drugalcdep.2012.05.029PubMedGoogle ScholarCrossref
28.
Degenhardt  LJ, Conigrave  KM, Wutzke  SE, Saunders  JB.  The validity of an Australian modification of the AUDIT questionnaire.  Drug Alcohol Rev. 2001;20(2):143-154. doi:10.1080/09595230124592Google ScholarCrossref
29.
Demartini  KS, Carey  KB.  Optimizing the use of the AUDIT for alcohol screening in college students.  Psychol Assess. 2012;24(4):954-963. doi:10.1037/a0028519PubMedGoogle ScholarCrossref
30.
Foxcroft  DR, Smith  LA, Thomas  H, Howcutt  S.  Accuracy of Alcohol Use Disorders Identification Test for detecting problem drinking in 18-35 year-olds in England: method comparison study.  Alcohol Alcohol. 2015;50(2):244-250. doi:10.1093/alcalc/agu095PubMedGoogle ScholarCrossref
31.
Gache  P, Michaud  P, Landry  U,  et al.  The Alcohol Use Disorders Identification Test (AUDIT) as a screening tool for excessive drinking in primary care: reliability and validity of a French version.  Alcohol Clin Exp Res. 2005;29(11):2001-2007. doi:10.1097/01.alc.0000187034.58955.64PubMedGoogle ScholarCrossref
32.
Gómez  A, Conde  A, Santana  JM, Jorrín  A.  Diagnostic usefulness of brief versions of Alcohol Use Disorders Identification Test (AUDIT) for detecting hazardous drinkers in primary care settings.  J Stud Alcohol. 2005;66(2):305-308. doi:10.15288/jsa.2005.66.305PubMedGoogle ScholarCrossref
33.
Gómez  A, Conde  A, Santana  JM, Jorrín  A, Serrano  IM, Medina  R.  The diagnostic usefulness of AUDIT and AUDIT-C for detecting hazardous drinkers in the elderly.  Aging Ment Health. 2006;10(5):558-561. doi:10.1080/13607860600637729PubMedGoogle ScholarCrossref
34.
Gryczynski  J, Kelly  SM, Mitchell  SG, Kirk  A, O’Grady  KE, Schwartz  RP.  Validation and performance of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) among adolescent primary care patients.  Addiction. 2015;110(2):240-247. doi:10.1111/add.12767PubMedGoogle ScholarCrossref
35.
Gual  A, Segura  L, Contel  M, Heather  N, Colom  J.  AUDIT-3 and AUDIT-4: effectiveness of two short forms of the Alcohol Use Disorders Identification Test.  Alcohol Alcohol. 2002;37(6):591-596. doi:10.1093/alcalc/37.6.591PubMedGoogle ScholarCrossref
36.
Harris  SK, Knight  JR  Jr, Van Hook  S,  et al.  Adolescent substance use screening in primary care: validity of computer self-administered versus clinician-administered screening.  Subst Abus. 2016;37(1):197-203. doi:10.1080/08897077.2015.1014615PubMedGoogle ScholarCrossref
37.
Isaacson  JH, Butler  R, Zacharek  M, Tzelepis  A.  Screening with the Alcohol use Disorders Identification Test (AUDIT) in an inner-city population.  J Gen Intern Med. 1994;9(10):550-553. doi:10.1007/BF02599279PubMedGoogle ScholarCrossref
38.
Kelly  SM, Gryczynski  J, Mitchell  SG, Kirk  A, O’Grady  KE, Schwartz  RP.  Validity of brief screening instrument for adolescent tobacco, alcohol, and drug use.  Pediatrics. 2014;133(5):819-826. doi:10.1542/peds.2013-2346PubMedGoogle ScholarCrossref
39.
Knight  JR, Sherritt  L, Harris  SK, Gates  EC, Chang  G.  Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT.  Alcohol Clin Exp Res. 2003;27(1):67-73. doi:10.1111/j.1530-0277.2003.tb02723.xPubMedGoogle ScholarCrossref
40.
Kokotailo  PK, Egan  J, Gangnon  R, Brown  D, Mundt  M, Fleming  M.  Validity of the Alcohol Use Disorders Identification Test in college students.  Alcohol Clin Exp Res. 2004;28(6):914-920. doi:10.1097/01.ALC.0000128239.87611.F5PubMedGoogle ScholarCrossref
41.
Kumar  PC, Cleland  CM, Gourevitch  MN,  et al.  Accuracy of the Audio Computer Assisted Self Interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ACASI ASSIST) for identifying unhealthy substance use and substance use disorders in primary care patients.  Drug Alcohol Depend. 2016;165:38-44. doi:10.1016/j.drugalcdep.2016.05.030PubMedGoogle ScholarCrossref
42.
Levola  J, Aalto  M.  Screening for at-risk drinking in a population reporting symptoms of depression: a validation of the AUDIT, AUDIT-C, and AUDIT-3.  Alcohol Clin Exp Res. 2015;39(7):1186-1192. doi:10.1111/acer.12763PubMedGoogle ScholarCrossref
43.
Levy  S, Dedeoglu  F, Gaffin  JM,  et al.  A screening tool for assessing alcohol use risk among medically vulnerable youth.  PLoS One. 2016;11(5):e0156240. doi:10.1371/journal.pone.0156240PubMedGoogle ScholarCrossref
44.
McCann  BS, Simpson  TL, Ries  R, Roy-Byrne  P.  Reliability and validity of screening instruments for drug and alcohol abuse in adults seeking evaluation for attention-deficit/hyperactivity disorder.  Am J Addict. 2000;9(1):1-9. doi:10.1080/10550490050172173PubMedGoogle ScholarCrossref
45.
McGinnis  KA, Justice  AC, Kraemer  KL, Saitz  R, Bryant  KJ, Fiellin  DA.  Comparing alcohol screening measures among HIV-infected and -uninfected men.  Alcohol Clin Exp Res. 2013;37(3):435-442. doi:10.1111/j.1530-0277.2012.01937.xPubMedGoogle ScholarCrossref
46.
McNeely  J, Strauss  SM, Saitz  R,  et al.  A brief patient self-administered substance use screening tool for primary care: two-site validation study of the Substance Use Brief Screen (SUBS).  Am J Med. 2015;128(7):784.e9-784.e19. doi:10.1016/j.amjmed.2015.02.007PubMedGoogle ScholarCrossref
47.
Northrup  TF, Malone  PS, Follingstad  D, Stotts  AL.  Using item response theory to improve alcohol dependence screening for African American and white male and female college students.  Addict Disord Their Treat. 2013;12(2):99-109. doi:10.1097/ADT.0b013e3182627431Google ScholarCrossref
48.
Piccinelli  M, Tessari  E, Bortolomasi  M,  et al.  Efficacy of the Alcohol Use Disorders Identification Test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study.  BMJ. 1997;314(7078):420-424. doi:10.1136/bmj.314.7078.420PubMedGoogle ScholarCrossref
49.
Rumpf  HJ, Hapke  U, Meyer  C, John  U.  Screening for alcohol use disorders and at-risk drinking in the general population: psychometric performance of three questionnaires.  Alcohol Alcohol. 2002;37(3):261-268. doi:10.1093/alcalc/37.3.261PubMedGoogle ScholarCrossref
50.
Rumpf  HJ, Wohlert  T, Freyer-Adam  J, Grothues  J, Bischof  G.  Screening questionnaires for problem drinking in adolescents: performance of AUDIT, AUDIT-C, CRAFFT and POSIT.  Eur Addict Res. 2013;19(3):121-127. doi:10.1159/000342331PubMedGoogle ScholarCrossref
51.
Santis  R, Garmendia  ML, Acuña  G, Alvarado  ME, Arteaga  O.  The Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument for adolescents.  Drug Alcohol Depend. 2009;103(3):155-158. doi:10.1016/j.drugalcdep.2009.01.017PubMedGoogle ScholarCrossref
52.
Seale  JP, Boltri  JM, Shellenberger  S,  et al.  Primary care validation of a single screening question for drinkers.  J Stud Alcohol. 2006;67(5):778-784. doi:10.15288/jsa.2006.67.778PubMedGoogle ScholarCrossref
53.
Smith  PC, Schmidt  SM, Allensworth-Davies  D, Saitz  R.  Primary care validation of a single-question alcohol screening test  [published correction appears in J Gen Intern Med. 2010;25(4):375].  J Gen Intern Med. 2009;24(7):783-788. doi:10.1007/s11606-009-0928-6PubMedGoogle ScholarCrossref
54.
Volk  RJ, Steinbauer  JR, Cantor  SB, Holzer  CE  III.  The Alcohol Use Disorders Identification Test (AUDIT) as a screen for at-risk drinking in primary care patients of different racial/ethnic backgrounds.  Addiction. 1997;92(2):197-206. doi:10.1111/j.1360-0443.1997.tb03652.xPubMedGoogle ScholarCrossref
55.
López  MB, Lichtenberger  A, Conde  K, Cremonte  M.  Psychometric properties of brief screening tests for alcohol use disorders during pregnancy in Argentina  [in Portugese].  Rev Bras Ginecol Obstet. 2017;39(7):322-329. doi:10.1055/s-0037-1603744PubMedGoogle ScholarCrossref
56.
McNeely  J, Wu  LT, Subramaniam  G,  et al.  Performance of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool for substance use screening in primary care patients.  Ann Intern Med. 2016;165(10):690-699. doi:10.7326/M16-0317PubMedGoogle ScholarCrossref
57.
Bradley  KA, DeBenedetti  AF, Volk  RJ, Williams  EC, Frank  D, Kivlahan  DR.  AUDIT-C as a brief screen for alcohol misuse in primary care.  Alcohol Clin Exp Res. 2007;31(7):1208-1217. doi:10.1111/j.1530-0277.2007.00403.xPubMedGoogle ScholarCrossref
58.
Bush  KR, Kivlahan  DR, Davis  TM,  et al.  The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients.  Alcohol Clin Exp Res. 2003;27(12):1971-1978. doi:10.1097/01.ALC.0000099262.50094.98PubMedGoogle ScholarCrossref
59.
Dawson  DA, Pulay  AJ, Grant  BF.  A comparison of two single-item screeners for hazardous drinking and alcohol use disorder.  Alcohol Clin Exp Res. 2010;34(2):364-374. doi:10.1111/j.1530-0277.2009.01098.xPubMedGoogle ScholarCrossref
60.
Frank  D, DeBenedetti  AF, Volk  RJ, Williams  EC, Kivlahan  DR, Bradley  KA.  Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups.  J Gen Intern Med. 2008;23(6):781-787. doi:10.1007/s11606-008-0594-0PubMedGoogle ScholarCrossref
61.
Johnson  JA, Lee  A, Vinson  D, Seale  JP.  Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: a validation study.  Alcohol Clin Exp Res. 2013;37(suppl 1):E253-E259. doi:10.1111/j.1530-0277.2012.01898.xPubMedGoogle ScholarCrossref
62.
McNeely  J, Cleland  CM, Strauss  SM, Palamar  JJ, Rotrosen  J, Saitz  R.  Validation of self-administered Single-Item Screening Questions (SISQs) for unhealthy alcohol and drug use in primary care patients.  J Gen Intern Med. 2015;30(12):1757-1764. doi:10.1007/s11606-015-3391-6PubMedGoogle ScholarCrossref
63.
Northrup  TF.  Effective measurement of problematic drinking for college students: reducing differential item functioning across gender and race.  Diss Abstr Int B Sci Eng. 2010;70(7-B):4492.Google Scholar
64.
Saitz  R, Cheng  DM, Allensworth-Davies  D, Winter  MR, Smith  PC.  The ability of single screening questions for unhealthy alcohol and other drug use to identify substance dependence in primary care.  J Stud Alcohol Drugs. 2014;75(1):153-157. doi:10.15288/jsad.2014.75.153PubMedGoogle ScholarCrossref
65.
Steinbauer  JR, Cantor  SB, Holzer  CE  III, Volk  RJ.  Ethnic and sex bias in primary care screening tests for alcohol use disorders.  Ann Intern Med. 1998;129(5):353-362. doi:10.7326/0003-4819-129-5-199809010-00002PubMedGoogle ScholarCrossref
66.
Wu  LT, McNeely  J, Subramaniam  GA, Sharma  G, VanVeldhuisen  P, Schwartz  RP.  Design of the NIDA clinical trials network validation study of Tobacco, Alcohol, Prescription medications, and Substance use/misuse (TAPS) tool.  Contemp Clin Trials. 2016;50:90-97. doi:10.1016/j.cct.2016.07.013PubMedGoogle ScholarCrossref
67.
Gryczynski  J, McNeely  J, Wu  LT,  et al.  Validation of the TAPS-1: a four-item screening tool to identify unhealthy substance use in primary care.  J Gen Intern Med. 2017;32(9):990-996. doi:10.1007/s11606-017-4079-xPubMedGoogle ScholarCrossref
68.
Whiting  P, Rutjes  AW, Reitsma  JB, Bossuyt  PM, Kleijnen  J.  The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews.  BMC Med Res Methodol. 2003;3:25. doi:10.1186/1471-2288-3-25PubMedGoogle ScholarCrossref
69.
Whiting  P, Wolff  R.  Medical use of cannabinoids—reply.  JAMA. 2015;314(16):1751-1752. doi:10.1001/jama.2015.11447PubMedGoogle ScholarCrossref
70.
Aalto  M, Saksanen  R, Laine  P,  et al.  Brief intervention for female heavy drinkers in routine general practice: a 3-year randomized, controlled study.  Alcohol Clin Exp Res. 2000;24(11):1680-1686. doi:10.1111/j.1530-0277.2000.tb01969.xPubMedGoogle ScholarCrossref
71.
Bertholet  N, Cunningham  JA, Faouzi  M,  et al.  Internet-based brief intervention for young men with unhealthy alcohol use: a randomized controlled trial in a general population sample.  Addiction. 2015;110(11):1735-1743. doi:10.1111/add.13051PubMedGoogle ScholarCrossref
72.
Bischof  G, Grothues  JM, Reinhardt  S, Meyer  C, John  U, Rumpf  HJ.  Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: a randomized controlled trial.  Drug Alcohol Depend. 2008;93(3):244-251. doi:10.1016/j.drugalcdep.2007.10.003PubMedGoogle ScholarCrossref
73.
Burge  SK, Amodei  N, Elkin  B,  et al.  An evaluation of two primary care interventions for alcohol abuse among Mexican-American patients.  Addiction. 1997;92(12):1705-1716. doi:10.1111/j.1360-0443.1997.tb02891.xPubMedGoogle ScholarCrossref
74.
Butler  CC, Simpson  SA, Hood  K,  et al.  Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial.  BMJ. 2013;346:f1191. doi:10.1136/bmj.f1191PubMedGoogle ScholarCrossref
75.
Carey  KB, Carey  MP, Maisto  SA, Henson  JM.  Brief motivational interventions for heavy college drinkers: a randomized controlled trial.  J Consult Clin Psychol. 2006;74(5):943-954. doi:10.1037/0022-006X.74.5.943PubMedGoogle ScholarCrossref
76.
Chang  G, Fisher  ND, Hornstein  MD,  et al.  Brief intervention for women with risky drinking and medical diagnoses: a randomized controlled trial.  J Subst Abuse Treat. 2011;41(2):105-114. doi:10.1016/j.jsat.2011.02.011PubMedGoogle ScholarCrossref
77.
Chang  G, McNamara  TK, Orav  EJ,  et al.  Brief intervention for prenatal alcohol use: a randomized trial.  Obstet Gynecol. 2005;105(5, pt 1):991-998. doi:10.1097/01.AOG.0000157109.05453.84PubMedGoogle ScholarCrossref
78.
Chang  G, Wilkins-Haug  L, Berman  S, Goetz  MA.  Brief intervention for alcohol use in pregnancy: a randomized trial.  Addiction. 1999;94(10):1499-1508. doi:10.1046/j.1360-0443.1999.941014996.xPubMedGoogle ScholarCrossref
79.
Collins  SE, Kirouac  M, Lewis  MA, Witkiewitz  K, Carey  KB.  Randomized controlled trial of web-based decisional balance feedback and personalized normative feedback for college drinkers.  J Stud Alcohol Drugs. 2014;75(6):982-992. doi:10.15288/jsad.2014.75.982PubMedGoogle ScholarCrossref
80.
Crawford  MJ, Sanatinia  R, Barrett  B,  et al.  The clinical effectiveness and cost-effectiveness of brief intervention for excessive alcohol consumption among people attending sexual health clinics: a randomised controlled trial (SHEAR).  Health Technol Assess. 2014;18(30):1-48. doi:10.3310/hta18300PubMedGoogle ScholarCrossref
81.
Cunningham  JA, Neighbors  C, Wild  C, Humphreys  K.  Ultra-brief intervention for problem drinkers: results from a randomized controlled trial.  PLoS One. 2012;7(10):e48003. doi:10.1371/journal.pone.0048003PubMedGoogle ScholarCrossref
82.
Curry  SJ, Ludman  EJ, Grothaus  LC, Donovan  D, Kim  E.  A randomized trial of a brief primary-care-based intervention for reducing at-risk drinking practices.  Health Psychol. 2003;22(2):156-165. doi:10.1037/0278-6133.22.2.156PubMedGoogle ScholarCrossref
83.
Daeppen  JB, Bertholet  N, Gaume  J, Fortini  C, Faouzi  M, Gmel  G.  Efficacy of brief motivational intervention in reducing binge drinking in young men: a randomized controlled trial.  Drug Alcohol Depend. 2011;113(1):69-75. doi:10.1016/j.drugalcdep.2010.07.009PubMedGoogle ScholarCrossref
84.
Drummond  C, Coulton  S, James  D,  et al.  Effectiveness and cost-effectiveness of a stepped care intervention for alcohol use disorders in primary care: pilot study.  Br J Psychiatry. 2009;195(5):448-456. doi:10.1192/bjp.bp.108.056697PubMedGoogle ScholarCrossref
85.
Emmen  MJ, Schippers  GM, Wollersheim  H, Bleijenberg  G.  Adding psychologist’s intervention to physicians’ advice to problem drinkers in the outpatient clinic.  Alcohol Alcohol. 2005;40(3):219-226. doi:10.1093/alcalc/agh137PubMedGoogle ScholarCrossref
86.
Ettner  SL, Xu  H, Duru  OK,  et al.  The effect of an educational intervention on alcohol consumption, at-risk drinking, and health care utilization in older adults: the Project SHARE study.  J Stud Alcohol Drugs. 2014;75(3):447-457. doi:10.15288/jsad.2014.75.447PubMedGoogle ScholarCrossref
87.
Fleming  MF, Balousek  SL, Grossberg  PM,  et al.  Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics.  J Stud Alcohol Drugs. 2010;71(1):23-31. doi:10.15288/jsad.2010.71.23PubMedGoogle ScholarCrossref
88.
Fleming  MF, Barry  KL, Manwell  LB, Johnson  K, London  R.  Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices.  JAMA. 1997;277(13):1039-1045. doi:10.1001/jama.1997.03540370029032PubMedGoogle ScholarCrossref
89.
Fleming  MF, Lund  MR, Wilton  G, Landry  M, Scheets  D.  The Healthy Moms Study: the efficacy of brief alcohol intervention in postpartum women.  Alcohol Clin Exp Res. 2008;32(9):1600-1606. doi:10.1111/j.1530-0277.2008.00738.xPubMedGoogle ScholarCrossref
90.
Fleming  MF, Manwell  LB, Barry  KL, Adams  W, Stauffacher  EA.  Brief physician advice for alcohol problems in older adults: a randomized community-based trial.  J Fam Pract. 1999;48(5):378-384.PubMedGoogle Scholar
91.
Hansen  AB, Becker  U, Nielsen  AS, Grønbæk  M, Tolstrup  JS, Thygesen  LC.  Internet-based brief personalized feedback intervention in a non-treatment-seeking population of adult heavy drinkers: a randomized controlled trial.  J Med Internet Res. 2012;14(4):e98. doi:10.2196/jmir.1883PubMedGoogle ScholarCrossref
92.
Haug  S, Paz Castro  R, Kowatsch  T, Filler  A, Dey  M, Schaub  MP.  Efficacy of a web- and text messaging-based intervention to reduce problem drinking in adolescents: results of a cluster-randomized controlled trial.  J Consult Clin Psychol. 2017;85(2):147-159. doi:10.1037/ccp0000138PubMedGoogle ScholarCrossref
93.
Heather  N, Campion  PD, Neville  RG, Maccabe  D.  Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS scheme).  J R Coll Gen Pract. 1987;37(301):358-363.PubMedGoogle Scholar
94.
Helstrom  AW, Ingram  E, Wang  W, Small  D, Klaus  J, Oslin  D.  Treating heavy drinking in primary care practices: evaluation of a telephone-based intervention program.  Addict Disord Their Treat. 2014;13(3):101-109. doi:10.1097/ADT.0b013e31827e206cGoogle ScholarCrossref
95.
Hilbink  M, Voerman  G, van Beurden  I, Penninx  B, Laurant  M.  A randomized controlled trial of a tailored primary care program to reverse excessive alcohol consumption.  J Am Board Fam Med. 2012;25(5):712-722. doi:10.3122/jabfm.2012.05.120070PubMedGoogle ScholarCrossref
96.
Johnsson  KO, Berglund  M.  Comparison between a cognitive behavioural alcohol programme and post-mailed minimal intervention in high-risk drinking university freshmen: results from a randomized controlled trial.  Alcohol Alcohol. 2006;41(2):174-180. doi:10.1093/alcalc/agh243PubMedGoogle ScholarCrossref
97.
Kaner  E, Bland  M, Cassidy  P,  et al.  Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial.  BMJ. 2013;346:e8501. doi:10.1136/bmj.e8501PubMedGoogle ScholarCrossref
98.
Kypri  K, Hallett  J, Howat  P,  et al.  Randomized controlled trial of proactive web-based alcohol screening and brief intervention for university students.  Arch Intern Med. 2009;169(16):1508-1514. doi:10.1001/archinternmed.2009.249PubMedGoogle ScholarCrossref
99.
Kypri  K, Langley  JD, Saunders  JB, Cashell-Smith  ML, Herbison  P.  Randomized controlled trial of web-based alcohol screening and brief intervention in primary care.  Arch Intern Med. 2008;168(5):530-536. doi:10.1001/archinternmed.2007.109PubMedGoogle ScholarCrossref
100.
Kypri  K, Saunders  JB, Williams  SM,  et al.  Web-based screening and brief intervention for hazardous drinking: a double-blind randomized controlled trial.  Addiction. 2004;99(11):1410-1417. doi:10.1111/j.1360-0443.2004.00847.xPubMedGoogle ScholarCrossref
101.
LaBrie  JW, Huchting  KK, Lac  A, Tawalbeh  S, Thompson  AD, Larimer  ME.  Preventing risky drinking in first-year college women: further validation of a female-specific motivational-enhancement group intervention.  J Stud Alcohol Drugs Suppl. 2009;(16):77-85. doi:10.15288/jsads.2009.s16.77PubMedGoogle Scholar
102.
Labrie  JW, Lewis  MA, Atkins  DC,  et al.  RCT of web-based personalized normative feedback for college drinking prevention: are typical student norms good enough?  J Consult Clin Psychol. 2013;81(6):1074-1086. doi:10.1037/a0034087PubMedGoogle ScholarCrossref
103.
Larimer  ME, Lee  CM, Kilmer  JR,  et al.  Personalized mailed feedback for college drinking prevention: a randomized clinical trial.  J Consult Clin Psychol. 2007;75(2):285-293. doi:10.1037/0022-006X.75.2.285PubMedGoogle ScholarCrossref
104.
Leeman  RF, DeMartini  KS, Gueorguieva  R,  et al.  Randomized controlled trial of a very brief, multicomponent web-based alcohol intervention for undergraduates with a focus on protective behavioral strategies.  J Consult Clin Psychol. 2016;84(11):1008-1015. doi:10.1037/ccp0000132PubMedGoogle ScholarCrossref
105.
Lewis  MA, Patrick  ME, Litt  DM,  et al.  Randomized controlled trial of a web-delivered personalized normative feedback intervention to reduce alcohol-related risky sexual behavior among college students.  J Consult Clin Psychol. 2014;82(3):429-440. doi:10.1037/a0035550PubMedGoogle ScholarCrossref
106.
Maisto  SA, Conigliaro  J, McNeil  M, Kraemer  K, Conigliaro  RL, Kelley  ME.  Effects of two types of brief intervention and readiness to change on alcohol use in hazardous drinkers.  J Stud Alcohol. 2001;62(5):605-614. doi:10.15288/jsa.2001.62.605PubMedGoogle ScholarCrossref
107.
Marlatt  GA, Baer  JS, Kivlahan  DR,  et al.  Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment.  J Consult Clin Psychol. 1998;66(4):604-615. doi:10.1037/0022-006X.66.4.604PubMedGoogle ScholarCrossref
108.
Martens  MP, Kilmer  JR, Beck  NC, Zamboanga  BL.  The efficacy of a targeted personalized drinking feedback intervention among intercollegiate athletes: a randomized controlled trial.  Psychol Addict Behav. 2010;24(4):660-669. doi:10.1037/a0020299PubMedGoogle ScholarCrossref
109.
Mason  M, Light  J, Campbell  L,  et al.  Peer network counseling with urban adolescents: a randomized controlled trial with moderate substance users.  J Subst Abuse Treat. 2015;58:16-24. doi:10.1016/j.jsat.2015.06.013PubMedGoogle ScholarCrossref
110.
Moore  AA, Blow  FC, Hoffing  M,  et al.  Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial.  Addiction. 2011;106(1):111-120. doi:10.1111/j.1360-0443.2010.03229.xPubMedGoogle ScholarCrossref
111.
Neighbors  C, Larimer  ME, Lewis  MA.  Targeting misperceptions of descriptive drinking norms: efficacy of a computer-delivered personalized normative feedback intervention.  J Consult Clin Psychol. 2004;72(3):434-447. doi:10.1037/0022-006X.72.3.434PubMedGoogle ScholarCrossref
112.
Neighbors  C, Lewis  MA, Atkins  DC,  et al.  Efficacy of web-based personalized normative feedback: a two-year randomized controlled trial.  J Consult Clin Psychol. 2010;78(6):898-911. doi:10.1037/a0020766PubMedGoogle ScholarCrossref
113.
Neighbors  C, Lewis  MA, LaBrie  J,  et al.  A multisite randomized trial of normative feedback for heavy drinking: social comparison versus social comparison plus correction of normative misperceptions.  J Consult Clin Psychol. 2016;84(3):238-247. doi:10.1037/ccp0000067PubMedGoogle ScholarCrossref
114.
Ockene  JK, Adams  A, Hurley  TG, Wheeler  EV, Hebert  JR.  Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work?  Arch Intern Med. 1999;159(18):2198-2205. doi:10.1001/archinte.159.18.2198PubMedGoogle ScholarCrossref
115.
O’Connor  MJ, Whaley  SE.  Brief intervention for alcohol use by pregnant women.  Am J Public Health. 2007;97(2):252-258. doi:10.2105/AJPH.2005.077222PubMedGoogle ScholarCrossref
116.
Ondersma  SJ, Beatty  JR, Svikis  DS,  et al.  Computer-delivered screening and brief intervention for alcohol use in pregnancy: a pilot randomized trial.  Alcohol Clin Exp Res. 2015;39(7):1219-1226. doi:10.1111/acer.12747PubMedGoogle ScholarCrossref
117.
Ondersma  SJ, Svikis  DS, Thacker  LR, Beatty  JR, Lockhart  N.  A randomised trial of a computer-delivered screening and brief intervention for postpartum alcohol use.  Drug Alcohol Rev. 2016;35(6):710-718. doi:10.1111/dar.12389PubMedGoogle ScholarCrossref
118.
Osterman  RL, Carle  AC, Ammerman  RT, Gates  D.  Single-session motivational intervention to decrease alcohol use during pregnancy.  J Subst Abuse Treat. 2014;47(1):10-19. doi:10.1016/j.jsat.2014.01.009PubMedGoogle ScholarCrossref
119.
Reynolds  KD, Coombs  DW, Lowe  JB, Peterson  PL, Gayoso  E.  Evaluation of a self-help program to reduce alcohol consumption among pregnant women.  Int J Addict. 1995;30(4):427-443. doi:10.3109/10826089509048735PubMedGoogle ScholarCrossref
120.
Richmond  R, Heather  N, Wodak  A, Kehoe  L, Webster  I.  Controlled evaluation of a general practice-based brief intervention for excessive drinking.  Addiction. 1995;90(1):119-132. doi:10.1111/j.1360-0443.1995.tb01016.xPubMedGoogle ScholarCrossref
121.
Rose  GL, Badger  GJ, Skelly  JM, MacLean  CD, Ferraro  TA, Helzer  JE.  A randomized controlled trial of brief intervention by interactive voice response.  Alcohol Alcohol. 2017;52(3):335-343.PubMedGoogle Scholar
122.
Rubio  DM, Day  NL, Conigliaro  J,  et al.  Brief motivational enhancement intervention to prevent or reduce postpartum alcohol use: a single-blinded, randomized controlled effectiveness trial.  J Subst Abuse Treat. 2014;46(3):382-389. doi:10.1016/j.jsat.2013.10.009PubMedGoogle ScholarCrossref
123.
Rubio  G, Jiménez-Arriero  MA, Martínez  I, Ponce  G, Palomo  T.  Efficacy of physician-delivered brief counseling intervention for binge drinkers.  Am J Med. 2010;123(1):72-78. doi:10.1016/j.amjmed.2009.08.012PubMedGoogle ScholarCrossref
124.
Saitz  R, Horton  NJ, Sullivan  LM, Moskowitz  MA, Samet  JH.  Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention: the screening and intervention in primary care (SIP) study.  Ann Intern Med. 2003;138(5):372-382. doi:10.7326/0003-4819-138-5-200303040-00006PubMedGoogle ScholarCrossref
125.
Schaus  JF, Sole  ML, McCoy  TP, Mullett  N, O’Brien  MC.  Alcohol screening and brief intervention in a college student health center: a randomized controlled trial.  J Stud Alcohol Drugs Suppl. 2009;(16):131-141. doi:10.15288/jsads.2009.s16.131PubMedGoogle Scholar
126.
Schulz  DN, Candel  MJ, Kremers  SP, Reinwand  DA, Jander  A, de Vries  H.  Effects of a web-based tailored intervention to reduce alcohol consumption in adults: randomized controlled trial.  J Med Internet Res. 2013;15(9):e206. doi:10.2196/jmir.2568PubMedGoogle ScholarCrossref
127.
Scott  E, Anderson  P.  Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption.  Drug Alcohol Rev. 1991;10(4):313-321. doi:10.1080/09595239100185371PubMedGoogle ScholarCrossref
128.
Senft  RA, Polen  MR, Freeborn  DK, Hollis  JF.  Brief intervention in a primary care setting for hazardous drinkers.  Am J Prev Med. 1997;13(6):464-470. doi:10.1016/S0749-3797(18)30143-0PubMedGoogle ScholarCrossref
129.
Turrisi  R, Larimer  ME, Mallett  KA,  et al.  A randomized clinical trial evaluating a combined alcohol intervention for high-risk college students.  J Stud Alcohol Drugs. 2009;70(4):555-567. doi:10.15288/jsad.2009.70.555PubMedGoogle ScholarCrossref
130.
Tzilos  GK, Sokol  RJ, Ondersma  SJ.  A randomized phase I trial of a brief computer-delivered intervention for alcohol use during pregnancy.  J Womens Health (Larchmt). 2011;20(10):1517-1524. doi:10.1089/jwh.2011.2732PubMedGoogle ScholarCrossref
131.
Upshur  C, Weinreb  L, Bharel  M, Reed  G, Frisard  C.  A randomized control trial of a chronic care intervention for homeless women with alcohol use problems.  J Subst Abuse Treat. 2015;51:19-29. doi:10.1016/j.jsat.2014.11.001PubMedGoogle ScholarCrossref
132.
van der Wulp  NY, Hoving  C, Eijmael  K, Candel  MJ, van Dalen  W, De Vries  H.  Reducing alcohol use during pregnancy via health counseling by midwives and internet-based computer-tailored feedback: a cluster randomized trial.  J Med Internet Res. 2014;16(12):e274. doi:10.2196/jmir.3493PubMedGoogle ScholarCrossref
133.
Voogt  CV, Kuntsche  E, Kleinjan  M, Engels  RC.  The effect of the “What Do You Drink” web-based brief alcohol intervention on self-efficacy to better understand changes in alcohol use over time: randomized controlled trial using ecological momentary assessment.  Drug Alcohol Depend. 2014;138:89-97. doi:10.1016/j.drugalcdep.2014.02.009PubMedGoogle ScholarCrossref
134.
Wallace  P, Cutler  S, Haines  A.  Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption.  BMJ. 1988;297(6649):663-668. doi:10.1136/bmj.297.6649.663PubMedGoogle ScholarCrossref
135.
Watkins  KE, Ober  AJ, Lamp  K,  et al.  Collaborative care for opioid and alcohol use disorders in primary care: the SUMMIT randomized clinical trial.  JAMA Intern Med. 2017;177(10):1480-1488. doi:10.1001/jamainternmed.2017.3947PubMedGoogle ScholarCrossref
136.
Watson  JM, Crosby  H, Dale  VM,  et al; AESOPS Trial Team.  AESOPS: a randomised controlled trial of the clinical effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care.  Health Technol Assess. 2013;17(25):1-158. doi:10.3310/hta17250PubMedGoogle ScholarCrossref
137.
Wilson  GB, Wray  C, McGovern  R,  et al.  Intervention to reduce excessive alcohol consumption and improve comorbidity outcomes in hypertensive or depressed primary care patients: two parallel cluster randomized feasibility trials.  Trials. 2014;15:235. doi:10.1186/1745-6215-15-235PubMedGoogle ScholarCrossref
138.
Aalto  M, Seppä  K, Mattila  P,  et al.  Brief intervention for male heavy drinkers in routine general practice: a three-year randomized controlled study.  Alcohol Alcohol. 2001;36(3):224-230. doi:10.1093/alcalc/36.3.224PubMedGoogle ScholarCrossref
139.
Anderson  P, Scott  E.  The effect of general practitioners’ advice to heavy drinking men.  Br J Addict. 1992;87(6):891-900. doi:10.1111/j.1360-0443.1992.tb01984.xPubMedGoogle ScholarCrossref
140.
Baer  JS, Kivlahan  DR, Blume  AW, McKnight  P, Marlatt  GA.  Brief intervention for heavy-drinking college students: 4-year follow-up and natural history.  Am J Public Health. 2001;91(8):1310-1316. doi:10.2105/AJPH.91.8.1310PubMedGoogle ScholarCrossref
141.
Barnes  AJ, Xu  H, Tseng  CH,  et al.  The effect of a patient-provider educational intervention to reduce at-risk drinking on changes in health and health-related quality of life among older adults: the Project SHARE study.  J Subst Abuse Treat. 2016;60:14-20. doi:10.1016/j.jsat.2015.06.019PubMedGoogle ScholarCrossref
142.
Cleveland  MJ, Lanza  ST, Ray  AE, Turrisi  R, Mallett  KA.  Transitions in first-year college student drinking behaviors: does pre-college drinking moderate the effects of parent- and peer-based intervention components?  Psychol Addict Behav. 2012;26(3):440-450. doi:10.1037/a0026130PubMedGoogle ScholarCrossref
143.
Coulton  S, Bland  M, Crosby  H,  et al.  Effectiveness and cost-effectiveness of opportunistic screening and stepped-care interventions for older alcohol users in primary care.  Alcohol Alcohol. 2017;52(6):655-664. doi:10.1093/alcalc/agx065PubMedGoogle ScholarCrossref
144.
Coulton  S, Dale  V, Deluca  P,  et al.  Screening for at-risk alcohol consumption in primary care: a randomized evaluation of screening approaches.  Alcohol Alcohol. 2017;52(3):312-317. doi:10.1093/alcalc/agx017PubMedGoogle ScholarCrossref
145.
Crawford  MJ, Sanatinia  R, Barrett  B,  et al.  The clinical and cost-effectiveness of brief advice for excessive alcohol consumption among people attending sexual health clinics: a randomised controlled trial.  Sex Transm Infect. 2015;91(1):37-43. doi:10.1136/sextrans-2014-051561PubMedGoogle ScholarCrossref
146.
Fleming  MF, Mundt  MP, French  MT, Manwell  LB, Stauffacher  EA, Barry  KL.  Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings.  Med Care. 2000;38(1):7-18. doi:10.1097/00005650-200001000-00003PubMedGoogle ScholarCrossref
147.
Fleming  MF, Mundt  MP, French  MT, Manwell  LB, Stauffacher  EA, Barry  KL.  Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis.  Alcohol Clin Exp Res. 2002;26(1):36-43. doi:10.1111/j.1530-0277.2002.tb02429.xPubMedGoogle ScholarCrossref
148.
Freeborn  DK, Polen  MR, Hollis  JF, Senft  RA.  Screening and brief intervention for hazardous drinking in an HMO: effects on medical care utilization.  J Behav Health Serv Res. 2000;27(4):446-453. doi:10.1007/BF02287826PubMedGoogle ScholarCrossref
149.
Gordon  AJ, Conigliaro  J, Maisto  SA, McNeil  M, Kraemer  KL, Kelley  ME.  Comparison of consumption effects of brief interventions for hazardous drinking elderly.  Subst Use Misuse. 2003;38(8):1017-1035. doi:10.1081/JA-120017649PubMedGoogle ScholarCrossref
150.
Grossbard  JR, Mastroleo  NR, Geisner  IM,  et al.  Drinking norms, readiness to change, and gender as moderators of a combined alcohol intervention for first-year college students.  Addict Behav. 2016;52:75-82. doi:10.1016/j.addbeh.2015.07.028PubMedGoogle ScholarCrossref
151.
Grossbard  JR, Mastroleo  NR, Kilmer  JR,  et al.  Substance use patterns among first-year college students: secondary effects of a combined alcohol intervention.  J Subst Abuse Treat. 2010;39(4):384-390. doi:10.1016/j.jsat.2010.07.001PubMedGoogle ScholarCrossref
152.
Grossberg  PM, Brown  DD, Fleming  MF.  Brief physician advice for high-risk drinking among young adults.  Ann Fam Med. 2004;2(5):474-480. doi:10.1370/afm.122PubMedGoogle ScholarCrossref
153.
Grothues  JM, Bischof  G, Reinhardt  S, Meyer  C, John  U, Rumpf  HJ.  Effectiveness of brief alcohol interventions for general practice patients with problematic drinking behavior and comorbid anxiety or depressive disorders.  Drug Alcohol Depend. 2008;94(1-3):214-220. doi:10.1016/j.drugalcdep.2007.11.015PubMedGoogle ScholarCrossref
154.
Kaner  E, Bland  M, Cassidy  P,  et al.  Screening and brief interventions for hazardous and harmful alcohol use in primary care: a cluster randomised controlled trial protocol.  BMC Public Health. 2009;9:287. doi:10.1186/1471-2458-9-287PubMedGoogle ScholarCrossref
155.
Kypri  K, Langley  JD, Saunders  JB, Cashell-Smith  ML.  Assessment may conceal therapeutic benefit: findings from a randomized controlled trial for hazardous drinking.  Addiction. 2007;102(1):62-70. doi:10.1111/j.1360-0443.2006.01632.xPubMedGoogle ScholarCrossref
156.
Lin  JC, Karno  MP, Tang  L,  et al.  Do health educator telephone calls reduce at-risk drinking among older adults in primary care?  J Gen Intern Med. 2010;25(4):334-339. doi:10.1007/s11606-009-1223-2PubMedGoogle ScholarCrossref
157.
Maisto  SA, Conigliaro  J, McNeil  M, Kraemer  K, Kelley  ME.  The relationship between eligibility criteria for participation in alcohol brief intervention trials and other alcohol and health-related variables.  Am J Addict. 2001;10(3):218-231. doi:10.1080/105504901750532102PubMedGoogle ScholarCrossref
158.
Manwell  LB, Fleming  MF, Mundt  MP, Stauffacher  EA, Barry  KL.  Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial.  Alcohol Clin Exp Res. 2000;24(10):1517-1524. doi:10.1111/j.1530-0277.2000.tb04570.xPubMedGoogle ScholarCrossref
159.
Mundt  MP, French  MT, Roebuck  MC, Manwell  LB, Barry  KL.  Brief physician advice for problem drinking among older adults: an economic analysis of costs and benefits.  J Stud Alcohol. 2005;66(3):389-394. doi:10.15288/jsa.2005.66.389PubMedGoogle ScholarCrossref
160.
Ockene  JK, Reed  GW, Reiff-Hekking  S.  Brief patient-centered clinician-delivered counseling for high-risk drinking: 4-year results.  Ann Behav Med. 2009;37(3):335-342. doi:10.1007/s12160-009-9108-5PubMedGoogle ScholarCrossref
161.
Paz Castro  R, Haug  S, Kowatsch  T, Filler  A, Schaub  MP.  Moderators of outcome in a technology-based intervention to prevent and reduce problem drinking among adolescents.  Addict Behav. 2017;72:64-71. doi:10.1016/j.addbeh.2017.03.013PubMedGoogle ScholarCrossref
162.
Reiff-Hekking  S, Ockene  JK, Hurley  TG, Reed  GW.  Brief physician and nurse practitioner-delivered counseling for high-risk drinking: results at 12-month follow-up.  J Gen Intern Med. 2005;20(1):7-13. doi:10.1111/j.1525-1497.2005.21240.xPubMedGoogle ScholarCrossref
163.
Reinhardt  S, Bischof  G, Grothues  J, John  U, Meyer  C, Rumpf  HJ.  Gender differences in the efficacy of brief interventions with a stepped care approach in general practice patients with alcohol-related disorders.  Alcohol Alcohol. 2008;43(3):334-340. doi:10.1093/alcalc/agn004PubMedGoogle ScholarCrossref
164.
Roberts  LJ, Neal  DJ, Kivlahan  DR, Baer  JS, Marlatt  GA.  Individual drinking changes following a brief intervention among college students: clinical significance in an indicated preventive context.  J Consult Clin Psychol. 2000;68(3):500-505. doi:10.1037/0022-006X.68.3.500PubMedGoogle ScholarCrossref
165.
Rossi  BV, Chang  G, Berry  KF, Hornstein  MD, Missmer  SA.  In vitro fertilization outcomes and alcohol consumption in at-risk drinkers: the effects of a randomized intervention.  Am J Addict. 2013;22(5):481-485. doi:10.1111/j.1521-0391.2013.12019.xPubMedGoogle ScholarCrossref
166.
Voogt  CV, Poelen  EA, Kleinjan  M, Lemmers  LA, Engels  RC.  The effectiveness of the “What Do You Drink” web-based brief alcohol intervention in reducing heavy drinking among students: a two-arm parallel group randomized controlled trial.  Alcohol Alcohol. 2013;48(3):312-321. doi:10.1093/alcalc/ags133PubMedGoogle ScholarCrossref
167.
Voogt  CV, Poelen  EA, Kleinjan  M, Lemmers  LA, Engels  RC.  Targeting young drinkers online: the effectiveness of a web-based brief alcohol intervention in reducing heavy drinking among college students: study protocol of a two-arm parallel group randomized controlled trial.  BMC Public Health. 2011;11:231. doi:10.1186/1471-2458-11-231PubMedGoogle ScholarCrossref
168.
Wilton  G, Moberg  DP, Fleming  MF.  The effect of brief alcohol intervention on postpartum depression.  MCN Am J Matern Child Nurs. 2009;34(5):297-302. doi:10.1097/01.NMC.0000360422.06486.c4PubMedGoogle ScholarCrossref
169.
Young  CM, Neighbors  C, DiBello  AM, Sharp  C, Zvolensky  MJ, Lewis  MA.  Coping motives moderate efficacy of personalized normative feedback among heavy drinking U.S. college students.  J Stud Alcohol Drugs. 2016;77(3):495-499. doi:10.15288/jsad.2016.77.495PubMedGoogle ScholarCrossref
170.
Cohen  J.  A power primer.  Psychol Bull. 1992;112(1):155-159. doi:10.1037/0033-2909.112.1.155PubMedGoogle ScholarCrossref
171.
U.S. Department of Veterans Affairs. QUERI—Quality Enhancement Research Initiative: AUDIT-C frequently asked questions. QUERI website. https://www.queri.research.va.gov/tools/alcohol-misuse/alcohol-faqs.cfm. 2014. Accessed September 26, 2017.
172.
Williams  EC, Rubinsky  AD, Chavez  LJ,  et al.  An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration.  Addiction. 2014;109(9):1472-1481. doi:10.1111/add.12600PubMedGoogle ScholarCrossref
173.
Jonas  DE, Miller  T, Ratner  S,  et al.  Implementation and quality improvement of a screening and counseling program for unhealthy alcohol use in an academic general internal medicine practice.  J Healthc Qual. 2017;39(1):15-27. doi:10.1097/JHQ.0000000000000069PubMedGoogle ScholarCrossref
174.
Higgins-Biddle  JC, Babor  TF.  A review of the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and USAUDIT for screening in the United States: past issues and future directions.  Am J Drug Alcohol Abuse. 2018;1-9. doi:10.1080/00952990.2018.1456545PubMedGoogle Scholar
175.
Madson  MB, Schutts  JW, Jordan  HR,  et al.  Identifying at-risk college student drinkers with the AUDIT-US: a receiver operating characteristic curve analysis  [published online August 1, 2018].  Assessment. doi:10.1177/1073191118792091PubMedGoogle Scholar
176.
Jonas  DE, Garbutt  JC, Amick  HR,  et al.  Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force.  Ann Intern Med. 2012;157(9):645-654. doi:10.7326/0003-4819-157-9-201211060-00544PubMedGoogle ScholarCrossref
177.
Jonas  DE, Amick  HR, Feltner  C,  et al.  Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis.  JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628PubMedGoogle ScholarCrossref
US Preventive Services Task Force
Evidence Report
November 13, 2018

Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Author Affiliations
  • 1Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
  • 2University of North Carolina at Chapel Hill
JAMA. 2018;320(18):1910-1928. doi:10.1001/jama.2018.12086
Abstract

Importance  Unhealthy alcohol use is common, increasing, and a leading cause of premature mortality.

Objective  To review literature on the effectiveness and harms of screening and counseling for unhealthy alcohol use to inform the US Preventive Services Task Force.

Data Sources  MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through October 12, 2017; literature surveillance through August 1, 2018.

Study Selection  Test accuracy studies and randomized clinical trials of screening and counseling to reduce unhealthy alcohol use.

Data Extraction and Synthesis  Independent critical appraisal and data abstraction by 2 reviewers. Counseling trials were pooled using random-effects meta-analyses.

Main Outcomes and Measures  Sensitivity, specificity, drinks per week, exceeding recommended limits, heavy use episodes, abstinence (for pregnant women), and other health, family, social, and legal outcomes.

Results  One hundred thirteen studies (N = 314 466) were included. No studies examined benefits or harms of screening programs to reduce unhealthy alcohol use. For adolescents (10 studies [n = 171 363]), 1 study (n = 225) reported a sensitivity of 0.73 (95% CI, 0.60 to 0.83) and specificity of 0.81 (95% CI, 0.74 to 0.86) using the AUDIT-C (Alcohol Use Disorders Identification Test–Consumption) to detect the full spectrum of unhealthy alcohol use. For adults (35 studies [n = 114 182]), brief screening instruments commonly reported sensitivity and specificity between 0.70 and 0.85. Two trials of the effects of interventions to reduce unhealthy alcohol use in adolescents (n = 588) found mixed results: one reported a benefit in high-risk but not moderate-risk drinkers, and the other reported a statistically significant reduction in drinking frequency for boys but not girls; neither reported health or related outcomes. Across all populations (68 studies [n = 36 528]), counseling interventions were associated with a decrease in drinks per week (weighted mean difference, −1.6 [95% CI, −2.2 to −1.0]; 32 studies [37 effects; n = 15 974]), the proportion exceeding recommended drinking limits (odds ratio [OR], 0.60 [95% CI, 0.53 to 0.67]; 15 studies [16 effects; n = 9760]), and the proportion reporting a heavy use episode (OR, 0.67 [95% CI, 0.58 to 0.77]; 12 studies [14 effects; n = 8108]), and an increase in the proportion of pregnant women reporting abstinence (OR, 2.26 [95% CI, 1.43 to 3.56]; 5 studies [n = 796]) after 6 to 12 months. Health outcomes were sparsely reported and generally did not demonstrate group differences in effect. There was no evidence that these interventions could be harmful.

Conclusions and Relevance  Among adults, screening instruments feasible for use in primary care are available that can effectively identify people with unhealthy alcohol use, and counseling interventions in those who screen positive are associated with reductions in unhealthy alcohol use. There was no evidence that these interventions have unintended harmful effects.

Introduction

Unhealthy alcohol use (including use that exceeds recommended limits, use that is having negative effects on health, or alcohol use disorder) was estimated to be the third leading preventable cause of mortality in the United States in 2000,1 with 9.8% of deaths attributable to alcohol consumption from 2006 to 2010.2 Unhealthy alcohol use is relatively common; in 2016 in the United States, 26% of adults and 4.9% of adolescents reported heavy use episodes (≥5 drinks on the same occasion on ≥1 day in the previous month, also referred to as binge episodes) and 6.6% of adults reported engaging in heavy drinking (≥5 drinks on the same occasion on ≥5 days) in the previous month.3 Alcohol use can exacerbate or cause a wide range of medical conditions commonly encountered in the primary care setting, including gastrointestinal, cardiopulmonary, dermatologic, reproductive, and neurologic conditions.4 Alcohol also interacts dangerously with many commonly used prescription and over-the-counter medications.5 Screening and counseling to reduce unhealthy alcohol use may prevent deleterious health effects and help prevent progression to more severe forms of unhealthy use.

In 2013, the US Preventive Services Task Force (USPSTF) recommended that clinicians screen adults 18 years or older for alcohol misuse and provide brief behavioral counseling interventions to those engaged in risky or hazardous drinking behaviors (B recommendation).6 The USPSTF concluded, however, that the evidence in adolescents was insufficient to evaluate the balance of benefits and harms of screening and behavioral counseling interventions to reduce alcohol misuse (I statement). This review was prepared to inform an updated recommendation by the USPSTF on the evidence related to screening test accuracy and benefits and harms of screening and counseling for unhealthy alcohol use in populations and settings relevant to US primary care.

Methods
Scope of Review

An analytic framework was developed with 5 key questions (KQs) (Figure 1) that examined the benefits (KQ1) and harms (KQ3) of screening for unhealthy alcohol use, screening test accuracy (KQ2), and benefits (KQ4) and harms (KQ5) of counseling interventions for unhealthy alcohol use. A draft of the analytic framework, review questions, and inclusion and exclusion criteria was posted on the USPSTF website from August 25, 2016, to September 21, 2016, for the purpose of gathering public input. Detailed methods (eg, more detailed information about inclusion and quality rating criteria, methods for grading the strength of evidence for key questions, expert review, and public comment process) are available in the full evidence report at http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/unhealthy-alcohol-use-in-adolescents-and-adults-screening-and-behavioral-counseling-interventions.

Data Sources and Searches

MEDLINE, PubMED (for publisher-supplied records only), PsycINFO, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2011, to October 12, 2017, and supplemented by checking reference lists from the prior 2013 review and other relevant reviews, covering literature published since January 1, 1985. ClinicalTrials.gov was searched for ongoing trials. From October 12, 2017, through August 1, 2018, surveillance was conducted through article alerts and targeted searches of journals with a high impact factor and journals relevant to the topic to identify major studies that might affect the conclusions or understanding of the evidence and therefore the related USPSTF recommendation. The last surveillance, conducted on August 1, 2018, identified no new studies. However, 1 recently published diagnostic accuracy study was subsequently identified that met the inclusion criteria; that study did not change the conclusions and therefore is cited in the Discussion section only.

Study Selection

Two reviewers, applying a priori inclusion criteria, independently reviewed 17 149 unique citations and 570 full-text articles (Figure 2; eTable 1 in the Supplement). The review included English-language fair- and good-quality studies conducted among adolescents (12 years or older) or adults in countries categorized as “very high” on the United Nations Human Development Index.8 For benefits and harms of screening (KQ1 and KQ3) and interventions (KQ4 and KQ5), randomized clinical trials were included, as were nonrandomized controlled intervention studies with an eligible control group (eg, usual care, minimal intervention, attention control) that reported an alcohol use outcome. A minimum of 6 months of follow-up was required to assess intervention benefits (KQ1 and KQ4), but there was no minimum requirement for harms (KQ3 and KQ5). For screening test accuracy (KQ2), studies of test accuracy reporting sensitivity and specificity compared with a structured or semistructured clinical interview, or computer-based versions of structured assessments, were included.

For studies of benefits or harms of unhealthy alcohol screening (KQ1 and KQ3) and screening test accuracy (KQ2), studies that were restricted to participants with unhealthy alcohol use were excluded. For benefits or harms of unhealthy alcohol screening (KQ1 and KQ3), trials were sought that tested the effects of a screening program compared with usual care or a similar unscreened control group. Screening test accuracy (KQ2) evidence was limited to screening instruments named in national-level recommendations related to screening for unhealthy alcohol use or that had evidence to support their use based on the previous review (AUDIT [Alcohol Use Disorders Identification Test], AUDIT-C [AUDIT Consumption], SASQ [Single Alcohol Screening Question], and variations of these). Additionally, instruments were selected that target important subpopulations, ie, adolescents (National Institute on Alcohol Abuse and Alcoholism [NIAAA] 2-item screener, BSTAD [Brief Screener for Tobacco, Alcohol, and Other Drugs], and variations of these), pregnant women (TWEAK, T-ACE), or older adults (CARET [Comorbidity Alcohol Risk Evaluation Too]), or that cover both drug and alcohol use (ASSIST [Alcohol, Smoking, and Substance Involvement Screening Test]). For benefits or harms of unhealthy alcohol screening (KQ1 and KQ3) and of counseling interventions to reduce unhealthy alcohol use (KQ4 and KQ5), studies using any screening instrument were eligible.

For evaluating counseling interventions to reduce unhealthy alcohol use (KQ4 and KQ5), trials of behavioral counseling—with or without referral—were included if they were conducted in or recruited from primary care or a health care system or could feasibly be implemented in or referred from primary care. Since pharmacotherapy is primarily relevant to patients with moderate or severe alcohol use disorder (AUD), studies of pharmacotherapy treatment were excluded.

Trials were required to enroll participants through screening for unhealthy alcohol use for at least half of their sample. Screening had to take place in settings comparable or applicable to primary care with a defined population (eg, primary care clinic, Special Supplemental Nutrition Program for Women, Infants, and Children, college freshmen orientation). Trials that identified patients though behavioral or mental health clinics, substance abuse treatment centers, emergency department and trauma centers, work sites (including occupational screening), inpatient or residential facilities, or other institutions (eg, correctional facilities) were excluded. Studies of participants with alcohol dependence or severe AUD (or >50% of the enrolled sample having alcohol dependence or severe AUD) were excluded. Also excluded were studies limited to treatment-seeking individuals, those with concomitant psychotic disorders, those presenting in an emergency setting, and others not generalizable to primary care (eg, inpatients, those court-mandated to treatment, those who were incarcerated).

Data Extraction and Quality Assessment

Included trials were critically appraised by 2 independent reviewers using criteria defined by the USPSTF and for test accuracy studies, supplemented with criteria from the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) (eTable 2 in the Supplement).7,9 Disagreements were resolved by a third reviewer.

Studies were rated as poor quality and excluded if there was an important limitation such as, among treatment trials, very high attrition (generally >40%); differential attrition between intervention groups (generally >20%); substantial lack of baseline comparability between groups without adjustment; or major concerns about the trial conduct, analysis, or reporting of results. For diagnostic accuracy studies, examples of important limitations warranting a “poor” quality rating included use of a reference standard that was not likely to categorize participants accurately, having the participant complete the screener after participating in an in-depth interview on his or her alcohol use, and/or lack of assurance that the study sample was representative of a relevant population. One reviewer abstracted descriptive and outcome data from fair- and good-quality studies into standardized evidence tables; a second checked for accuracy and completeness.

Data Synthesis and Analysis

Summary tables of study, population, and intervention characteristics were created, along with forest plots of outcomes, to examine the size, consistency, and precision of effects. Studies were grouped according to population: adolescents (≈12 to 18 years), young adults (≈18 to 25 years), general adult populations (≈18 years or older), older adults (≈65 years or older), and pregnant and postpartum (up to 1 year after childbirth) women.

For the analysis of screening test accuracy, data were not pooled because of variability in cutoffs, populations, and screening tests. Contingency tables were used to calculate confidence intervals for sensitivity and specificity. If contingency tables were not reported, they were estimated using the reported sensitivity, specificity, and prevalence. Positive and negative predictive values were estimated based on the population prevalence of unhealthy alcohol use3 and 3 combinations of sensitivity and specificity. This article reports the test accuracy to screen for the full spectrum of unhealthy alcohol use (inclusive of exceeding limits and AUD). Test accuracy for other conditions (alcohol dependence, AUD, and exceeding limits) can be found in the full report.

For intervention effectiveness, meta-analysis was conducted for 4 alcohol use outcomes: drinks per week, drinking that exceeded recommended limits, heavy use episodes, and abstinence (for pregnant women). All related outcomes were converted to drinks per week, such as when provided with other time frames (eg, drinks per month) or with grams of ethanol rather than drinks. The conversion factor of 14 g of ethanol was used for 1 standard drink, since this is the definition of a standard drink in the United States. To determine whether meta-analyses were appropriate, clinical and methodological heterogeneity were assessed. In general, when at least 5 similar studies were available or when there were fewer studies but statistical heterogeneity was very low, quantitative synthesis was conducted and reported. Few health outcomes were reported in enough trials to consider pooling; however, a meta-analysis of mortality and alcohol problems or consequences was conducted.

Random-effects models were performed using the DerSimonian and Laird method to estimate pooled effects.10 For analyses that showed statistically significant pooled effects but that had fewer than 10 trials and I2 values larger than 50%, a sensitivity analysis was performed that used a more conservative pooling method to determine whether statistical significance was sustained (profile likelihood model or, if the profile likelihood model did not converge, a restricted maximum likelihood analysis with the Knapp-Hartung correction for small samples). For outcomes with 10 or more trials in the meta-analysis (drinks per week, exceeding recommended limits, and heavy use episodes), funnel plots were generated and the Egger test was used to examine funnel plot asymmetry to explore small-study effects, which can be related to publication bias.11 Additionally, for the outcome drinks per week, which was the most commonly reported outcome, meta-regression and subgroup analyses were conducted to explore factors associated with effect size.

Stata version 13.1 (StataCorp) was used for all analyses. All significance testing was 2-tailed, and results were considered statistically significant if the P value was .05 or less.

Results

Two reviewers independently assessed 17 149 unique abstracts and 570 full-text articles for inclusion (Figure 2). One hundred thirteen studies (N = 314 466) were included. Overall, 0 studies were included for KQ1, 45 studies (56 articles) for KQ2, 0 studies for KQ3, 68 studies (103 articles) for KQ4, and 11 studies (12 articles) for KQ5.

Benefits of Screening

Key Question 1a. Does primary care screening for unhealthy alcohol use in adolescents and adults, including pregnant women, reduce alcohol use or improve other risky behaviors?

No eligible studies were identified.

Key Question 1b. Does primary care screening for unhealthy alcohol use in adolescents and adults, including pregnant women, reduce morbidity or mortality or improve other health, social, or legal outcomes?

No eligible studies were identified.

Key Question 2. What is the accuracy of commonly used instruments to screen for unhealthy alcohol use?

Forty-five studies12-56 were included (reported in 56 publications12-67) (Table 1) that addressed the accuracy of screening instruments: 10 in adolescents,20,21,25,34,36,38,39,43,50,51 5 in young adults,14,23,29,40,47 27 in general adult populations,12,15-18,22,24,26-28,30-33,35,37,41,42,44-46,48,49,52-54,56 1 in older adults,13 and 2 in pregnant19 or postpartum55 women. One study in a general adult population provided subgroup analyses of pregnant women and older adults,26,59 and 1 study of participants aged 12 to 20 years provided subgroup analyses of young adults (18 to 20 years).21 The majority of studies were conducted in the United States (28/45 [62%]) and recruited patients from primary care (23/45 [51%]) (Table 1). The number of study participants ranged from 95 to 166 165. A variety of 1- and 2-item screening tests were used in the included studies, as well as the AUDIT, AUDIT-C, and ASSIST. Reference standards used in the included studies were most commonly structured diagnostic interviews, and the interview sometimes was used in combination with other instruments (eg, Timeline Followback). Most studies were fair quality (28/45 [62%]).

For adolescents, just 1 study (n = 225) in a German high school reported on test accuracy for detecting the full spectrum of unhealthy alcohol use (eFigure 1 in the Supplement), finding a sensitivity of 0.73 (95% CI, 0.60 to 0.83) and specificity of 0.81 (95% CI, 0.74 to 0.86) for the optimal cutoff of 5 or higher on the AUDIT-C (male and female participants combined). The majority of the test accuracy evidence for adolescents was to detect AUD and is available in the full evidence report.

For adults, studies of the NIAAA-recommended single-item question (How many times in the past year have you had 5 or 4 [males or females, respectively] or more drinks in a day?) reported sensitivity ranging from 0.73 to 0.88 (95% CI range, 0.65 to 0.89) and specificity ranging from 0.74 to 1.0 (95% CI range, 0.69 to 1.0) for detecting the full spectrum of unhealthy alcohol use (4 studies [n = 44 461]) (Figure 3, labeled “5/4+ drinks”). All of these studies were conducted in the United States, primarily in primary care settings. Other 1- and 2-item screening tests (8 studies [n = 48 211]) generally showed sensitivities of 0.70 or higher, although the standard of 6 or more drinks per occasion tended to have lower sensitivity than the 5/4 or more drinks standard, often with nonoverlapping confidence intervals. Other adult populations (young adults, older adults, pregnant women) had results in similar ranges.

For the AUDIT-C, sensitivity for detecting the full spectrum of unhealthy alcohol use in adults was similar to the 1- and 2-item screeners, excluding 1 Veterans Affairs–based study in HIV-positive patients and matched controls45 that had substantially lower sensitivity. In most studies, the range of sensitivities was 0.73 to 0.97 for female participants (5 studies [n = 2714]; 95% CI range, 0.62 to 0.99) (eFigure 2 in the Supplement) and 0.82 to 1.0 for male participants (4 studies [n = 1038]; 95% CI range, 0.75 to 1.0) (eFigure 3 in the Supplement) at the standard score cutoffs of 3 or higher for female participants and 4 or higher for male participants, but the range of reported specificity was much wider (0.28 to 0.91 [95% CI range, 0.21 to 0.93] for female participants and 0.34 to 0.89 [95% CI range, 0.25 to 0.92] for male participants). Several studies reported sensitivities of 0.80 or higher at optimal cutoffs on the AUDIT-C, with associated specificities generally in the range of mid-0.70s to mid-0.80s (eFigure 1 in the Supplement). Evidence on the use of the AUDIT-C was very sparse in the adult subpopulations of younger adults, older adults, and pregnant women.

For the AUDIT, when using the recommended score cutoff of 8 or higher, studies (7 studies [n = 8852]) reported a wide range of sensitivity for detecting the full spectrum of unhealthy alcohol use in general adult populations (range, 0.38 to 0.73 [95% CI range, 0.33 to 0.84]) but high specificity (range, 0.89 to 0.97 [95% CI range, 0.84 to 0.98]) (eFigure 4 in Supplement). Sensitivity was relatively high (0.82) in young adults at the standard score cutoff of 8 or higher, but data were sparse in this population (2 studies [n = 660]). In many studies, sensitivity improved at lower cutoffs. Studies conducted in US primary care settings generally showed a more optimal balance of sensitivity and specificity at cutoffs of 3, 4, or 5 (3 trials [n = 2782]; sensitivity range, 0.64 to 0.86 [95% CI range, 0.57 to 0.91]; specificity range, 0.74 to 0.94 [95% CI range, 0.68 to 0.95]) (eFigure 5 in the Supplement).

At a sensitivity of 0.80 and a specificity of 0.90, the positive predictive value was estimated at 74% and the negative predictive value was estimated at 93% among adults with heavy use episodes in the past month (eTable 4 in the Supplement), using prevalence estimates for the US general population. Among population groups with lower prevalence of unhealthy alcohol use—older adults, pregnant women, and adolescents—the estimated positive predictive value was much lower, ranging from 26% to 46%.

Harms of Screening

Key Question 3. What are the harms of screening for unhealthy alcohol use in adolescents and adults, including pregnant women?

No eligible studies were identified.

Benefits of Interventions

Key Question 4a. Do counseling interventions to reduce unhealthy alcohol use, with or without referral, reduce unhealthy alcohol use or improve other risky behaviors in screen-detected persons?

Sixty-eight trials70-137 (n = 36528) were included (reported in 100 publications70-169) that addressed the effect of a counseling intervention on alcohol use. Two of the trials targeted adolescents,92,109 22 targeted college-aged or young adults,71,75,79,83,87,96,98-101,103-105,107,108,111-113,125,129,133 29 addressed general adult populations,70,72-74,76,80-82,84,85,88,91,93-95,97,106,114,120,122,124,126-128,131,134,137 4 focused on older adults,86,90,110,136 and 11 targeted pregnant77,78,115,116,118,119,123,130,132 or postpartum89,117 women. Details of the included trials are reported in eTable 3 in the Supplement. Most trials were conducted in the United States (41/68 [60%]) and in primary care settings (42/68 [62%]). Trials were typically limited to participants who reported a prespecified level of alcohol use (most commonly either more than 7 [female participants] or 14 [male participants] drinks per week on average, or 4 [female participants] or 5 [male participants] or more drinks on a single occasion) or scored above a predetermined cutoff on a screening instrument such as the AUDIT. Ten trials were rated as good quality71,86,88,91,92,100,123,129,133,136 and the remaining were fair quality. Nineteen trials (28%) were included in the previous review.

Most interventions involved 1 to 2 sessions (90% involved 4 or fewer sessions), with a median of 30 minutes of contact time (88% involved 2 hours of contact or less) (Table 2). Almost all interventions involved at least basic education; general feedback, such as how the participant’s drinking compared with recommended limits; and suggestions about how to reduce alcohol use. Many, particularly those in primary care settings, used a SBIRT (screening, brief intervention, and referral to treatment) approach, consistent with approaches recommended by several health organizations. The most commonly reported intervention element was the use of personalized normative feedback sessions, in which participants were shown how their alcohol use compared with that of others; this technique was used in 62% of the included interventions and 89% of the interventions in younger adults. Motivational techniques were also common, particularly in combination with personalized normative feedback.

Most trials in adolescents and young adults involved 1 or 2 in-person or web-based personalized normative feedback sessions in school or university settings. Counseling interventions targeting adults other than college students (including pregnant and postpartum women) were more likely to take place in primary care settings, have multiple sessions, and involve the primary care team in some way; 33% of the interventions were delivered by the primary care clinician in trials of general and older adult populations.

Six trials (in 7 intervention groups) incorporated feedback on how an individual’s alcohol consumption was affecting his or her health, such as elevated liver enzyme levels, symptoms or medical conditions that could be exacerbated by alcohol use, and potentially dangerous alcohol use with prescribed medications.73,86,93,110,132,134

The most commonly reported alcohol use outcome was drinks per week, reported in 45 trials. On average, individuals in intervention groups reduced their drinking by 1.6 drinks per week more than those in control groups after 6 to 12 months (32 trials and 37 analysis groups [n = 15 974]; weighted mean difference [WMD] between groups in change from baseline, −1.6 [95% CI, −2.2 to −1.0]; I2 = 63%) (Figure 4, Table 3). This analysis included only 1 trial in adolescents, with separate entries for moderate- and high-risk users, and so is primarily reflective of adult unhealthy alcohol users. Baseline use levels were highly variable, with trial baseline means ranging from 3.8 to 59.3 drinks per week across all populations, and larger effects were typically seen with larger baseline use levels. The intervention group means changed from 20.5 drinks per week at baseline to 15.6 drinks per week at follow-up; control group means changed from 20.1 at baseline to 17.4 at follow-up. Excluding trials in adolescents and young adults, whose drinking patterns were generally typified by heavy use episodes rather than daily heavy drinking, the mean drinks per week in adult populations changed from 26.0 at baseline to 19.1 at follow-up in the intervention groups and from 25.6 at baseline to 21.6 in the control groups.

Trials that could not be included in the meta-analysis generally showed effects of a similar or slightly smaller size, favoring the intervention group (eg, between-group differences in change ranging from 0.9 to 1.8 drinks/wk, or posttest differences of 2.3 drinks/wk, or 10% to 20% relative reductions in use). The associations remained statistically significant when limited to trials conducted in primary care settings (21 trials [n = 7803]; WMD, −2.4 [95% CI, −3.4 to −1.3]; I2 = 70%), in the United States (18 trials [n = 8766]; WMD, −1.3 [95% CI, −1.9 to −0.6]; I2 = 64%), and in US-based primary care settings (9 trials [n=4989]; WMD, −1.8 [95% CI, −2.9 to −0.6]; I2 = 77%) (Figure 5). For trials with multiple follow-up assessments, effects were typically maintained between 6 and 12 months of follow-up; however, in several trials of young adults, group differences at 6 months’ follow-up were no longer statistically significant at 12 months’ follow-up.75,87,99,125 Seven trials70,88,90,95,102,107,114 reported follow-up at 24 months or beyond, and group differences were maintained in 4 of these through 24 months90,107,112 to 48 months.88

A small-studies effect was identified for drinks per week (Egger test bias coefficient, −1.04; P = .03) (eFigure 6 in the Supplement), and earlier publication date, younger population age (young adults vs other adults), and higher baseline drinking levels were also associated with larger effect sizes (Figure 5). These factors were not independent of each other, however, and it could not be determined which had a causal association with effect size. Smaller trials were more likely to have been published before 2007 and to have been conducted among heavier drinkers. Older trials were also primarily conducted among general adult populations in primary care settings, whereas many of the newer trials were conducted among young adults in college settings, with baseline use levels that were considerably lower than those in trials targeting general adult populations. Associations between effect size and intervention elements or other populations or study characteristics were generally not found.

The intervention was associated with a reduction in the odds of exceeding recommended drinking limits at 6 to 12 months of follow-up (15 trials [16 effects; n = 9760]; odds ratio [OR], 0.60 [95% CI, 0.53 to 0.67]; I2 = 24%) (Table 3; eFigure 7 in the Supplement), although this outcome was reported in only 24% (16/68) of the included studies. Between 15% and 76% of participants exceeded recommended drinking limits at follow-up in the intervention groups, compared with 29% to 82% in the control groups. Similarly, there was a reduction in the pooled odds of reporting an episode of heavy use (12 trials [14 effects; n = 8108]; OR, 0.67 [95% CI, 0.58 to 0.77]; I2 = 24% (Table 3; eFigure 8 in the Supplement), which was also relatively sparsely reported. Between 10% and 76% of intervention participants reported heavy use episodes at follow-up, compared with 13% to 92% in control groups. Small-studies effects were not detected for either of these outcomes. The 9 trials in pregnant women were most likely to report the odds of abstinence rather than the aforementioned outcomes; abstinence was higher in the intervention groups compared with the control groups (5 trials [n = 796]; pooled OR, 2.26 [95% CI, 1.43 to 3.56]; I2 = 0%) ( Table 3; eFigure 9 in the Supplement). Among trials reporting abstinence before delivery, abstinence ranged from 72% to 90% among intervention participants and from 55% to 74% among control participants. Other alcohol use outcomes were very sparsely reported and generally showed no statistically significant differences between groups.

Few changes in other behavioral outcomes such as drug use, sex after alcohol use, and seeking help for unhealthy alcohol use were noted, and those outcomes were only rarely reported. One trial82 in a general adult population found a reduction in self-reported drinking and driving, but 2 trials, in younger125 and older86 adults, did not. The latter trial in older adults also reported that participants reduced the likelihood of using alcohol in the face of symptoms or comorbidities that could be exacerbated by alcohol and with medication that could interact negatively with alcohol.86

Key Question 4b. Do counseling interventions to reduce unhealthy alcohol use, with or without referral, reduce morbidity or mortality or improve other health, social, or legal outcomes in screen-detected persons?

The most commonly reported health outcome was alcohol-related problems or consequences, measured using a variety of instruments. A pooled analysis showed a statistically significant, but very small, standardized mean difference in change between groups of −0.04 (18 trials [n = 9894]; 95% CI, −0.09 to −0.01; I2 = 3%). This effect size (Hedges g) can be interpreted as a Cohen d, where a small effect is typically considered to be 0.20 to 0.50.170 Mortality was reported in 8 trials, primarily as part of the description of the participant retention. The pooled association was not statistically significant (9 trials [n = 4533]; OR, 0.64 [95% CI, 0.34 to 1.19]; I2 = 0%) (eFigure 10 in the Supplement) and also may represent an overestimate of the true effect, since some trials that did not report deaths likely had no deaths, particularly trials among young adults. Trials were not powered for this outcome and many had very few events, resulting in imprecise results.

One trial, the Trial for Early Alcohol Treatment (TrEAT), described ascertainment methods.88 The effect on mortality at 4 years, 0.8% (3/392) of intervention participants dying compared with 1.8% (7/382) of control participants, was not statistically significant. Differences in mortality between groups were statistically significant at 3 years of follow-up, when there had been only 1 death among intervention participants but 7 among controls. This trial also reported statistically significant reductions in days of hospitalization (420 in the intervention group vs 664 in the control group) and controlled substance or liquor violations (2 in the intervention group vs 11 in the control group) at 4 years of follow-up. Other trials reported a wide variety of health outcomes, generally at 6 to 12 months of follow-up, with few findings of benefit for intervention over control groups.

Harms of Interventions

Key Question 5. What are the harms of interventions to reduce unhealthy alcohol use in screen-detected persons?

Only 6 of the included trials (n = 3650) of counseling interventions to reduce unhealthy alcohol use reported on harms.72,103,105,113,116,136 In all cases, authors reported no harms in both groups. Further, no pattern of unexpected paradoxical increases in alcohol use was noted with these interventions.

Discussion

The evidence in this review is summarized in Table 4. No evidence was found for screening programs to reduce unhealthy alcohol use or improve health, compared with usual care without screening. Multiple screening instruments are available that can detect unhealthy alcohol use with reasonable accuracy and that require 1 or 2 minutes to administer. For example, studies of adults found that the NIAAA-recommended single question had sensitivity ranging from 0.73 to 0.88 and specificity from 0.74 to 1.0 for detecting unhealthy alcohol use. For the AUDIT-C, sensitivity was similar, but the range of reported specificity was wider. For the full AUDIT, range of sensitivity was wide (0.38-0.73) using the recommended score cutoff of 8 or higher, but range of specificity was high (0.89-0.97). This pattern supports the use of a brief screener to identify excess use, followed by assessment with a more detailed instrument with greater specificity (eg, the AUDIT), as is currently done in some health care systems.171-173 If used as an initial screening test, data for the AUDIT from US primary care settings suggests that lower cutoffs (eg, 3, 4, or 5) may be preferable to provide a more optimal balance of sensitivity and specificity for detecting the full spectrum of unhealthy alcohol use. Given the relatively brief time required for follow-up questions after a positive screen to confirm the presence of unhealthy alcohol use and determine its extent (if present), clinicians may prioritize sensitivity over specificity for the initial screening and may consider calibrating the optimal cutoff for their setting.

One limitation of the evidence on the accuracy of screening instruments is that studies sometimes used variations of the standard instruments and cutpoints, and the gold standard was also heterogeneous across studies (eg, the definition of “exceeding recommended limits” varied across countries). This likely increased the variability in results but also supports the robustness of these tools, even with modifications. Use of the USAUDIT and USAUDIT-C, designed to use the United States’ standard drink size and to return results consistent with NIAAA recommendations, is likely to improve on the performance of the standard AUDIT and AUDIT-C.174 No studies on the USAUDIT or USAUDIT-C were published during the search window; however, a newly published study conducted among college students confirms that the performance characteristics of these instruments are improved over those of the standard AUDIT and AUDIT-C for determining whether someone exceeds the NIAAA-recommended drinking limits.175

Among adults identified through screening, counseling interventions to reduce unhealthy alcohol use were associated with reductions in alcohol use (by a mean of 1.6 drinks/wk) and in the odds of exceeding recommended drinking limits (by 40%) and heavy use episodes (by 33%) at 6 to 12 months of follow-up. Based on these findings, among adult unhealthy alcohol users, and assuming 33% of control group participants were drinking within recommended limits at follow-up (the median of the included trials), such interventions would result in an absolute increase of 14 percentage points in the likelihood of drinking within recommended limits, meaning 7 adults would need to be treated to achieve 1 drinking within recommended limits (number needed to treat [NNT], 7.2 [95% CI, 6.2 to 11.5]). Among pregnant women, counseling interventions were associated with an odds ratio of 2.26 for remaining abstinent from alcohol during pregnancy, for an NNT of 6.0 (95% CI, 4.3 to 12.5), assuming a baseline rate of 62% of women being abstinent from alcohol. Very limited data suggested that benefits from alcohol use counseling interventions can be maintained over 2 to 4 years.

Although many trials reported health, social, legal, and related outcomes, no specific outcomes were widely reported. Very limited information on harms of the included intervention was found, but the fact that most results favored the intervention groups across a wide range of outcomes, even though differences were not always statistically significant, suggests very low risk of harm. Several studies reported on the acceptability of their interventions to participants and generally reported positive to very positive ratings.79,97,116,117,130

Findings in the current review were generally consistent with the findings of the previous USPSTF review.176 For test accuracy, the previous reviewers concluded that a single-question screener, the AUDIT-C, and the AUDIT appeared to be the best overall instruments for screening adults for the full spectrum of unhealthy alcohol use in primary care, with ranges of sensitivities and specificities solidly in the range of the sensitivities and specificities seen in this review among studies of adults. In the current review, original studies were examined rather than existing systematic reviews, and at least 60% of the studies included in this review were newly published since the previous review. Among the newly included evidence are 10 studies in adolescents, who were not previously represented.

For counseling interventions, overall, the pooled effect size for drinks per week was larger in the previous review,176 although results were quite similar for general and older adult populations and for other drinking outcomes. One of the main differences between the 2 reviews is the inclusion of studies conducted outside of primary care settings in the current review, which resulted in the inclusion of a substantial number of studies in college settings. Consistent with the previous review was the finding of a fairly large but statistically nonsignificant association between interventions and reduced all-cause mortality (OR, 0.64 [95% CI, 0.34 to 1.19] in the current review; relative risk, 0.52 [95% CI, 0.22 to 1.22] in the previous review).

Areas for future research include direct comparisons of screening programs with usual care (without universal screening); further evaluations of the versions of the AUDIT and AUDIT-C recently developed for the United States (USAUDIT and USAUDIT-C); interventions to reduce unhealthy alcohol use in populations of adolescents, young adults, and older adults in health care settings; and exploration of more intensive intervention approaches with young adults. One important limitation of evidence on the benefits and harms of alcohol counseling interventions is the lack of a consistently reported group of outcomes. It would be beneficial for trials to routinely report outcomes with the greatest clinical meaning, such as the proportion of participants drinking within recommended limits, and to report health (including alcohol-related medical conditions), social, and legal outcomes. It would also be useful for trials to commit a priori to reporting subgroup effects in important subpopulations, such as by age group, sex, race/ethnicity, and baseline severity.

Limitations

This evidence review has several limitations. First, comparative effectiveness trials—which have the potential to identify important features or mechanisms of change—were not included; however, other reviews that have included comparative effectiveness reviews have had very limited success in identifying mechanisms of change. Second, evidence regarding use of medication in treatment of AUD was not included. While this is primarily relevant to individuals being treated for more severe disorders rather than to most people with unhealthy alcohol use in screen-detected samples, medication would likely be appropriate for some patients identified through screening. A previous review found that multiple medications were associated with reductions in drinking and maintenance of abstinence for people with moderate to severe AUD, with NNTs from 12 to 20.177 Third, among adolescents, trials addressing prevention of unhealthy alcohol use were not included. This was outside the scope of the review but may be an important body of literature to consider when developing recommendations for adolescents.

Conclusions

Among adults, screening instruments feasible for use in primary care are available that can effectively identify people with unhealthy alcohol use, and counseling interventions in those who screen positive are associated with reductions in unhealthy alcohol use. There was no evidence that these interventions have unintended harmful effects.

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Article Information

Corresponding Author: Elizabeth A. O’Connor, PhD, Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Ave, Portland, OR 97227 (elizabeth.oconnor@kpchr.org).

Accepted for Publication: July 27, 2018.

Author Contribution: Dr O’Connor had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: O’Connor, Perdue, Patnode, Jonas.

Acquisition, analysis, or interpretation of data: O’Connor, Perdue, Senger, Rushkin, Bean, Jonas.

Drafting of the manuscript: O’Connor, Rushkin, Bean, Jonas.

Critical revision of the manuscript for important intellectual content: O’Connor, Perdue, Senger, Patnode, Jonas.

Statistical analysis: O’Connor, Perdue, Jonas.

Administrative, technical, or material support: Perdue, Senger, Rushkin, Patnode, Bean, Jonas.

Supervision: Jonas.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This research was funded under contract HHSA-290-2015-000017-I-EPC5, Task Order No. 2 from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the USPSTF.

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project: Ernest Sullivent, MD, MPH, and Amanda Borsky, DrPH, MPP (AHRQ); current and former members of the US Preventive Services Task Force who contributed to topic deliberations; Richard Saitz, MD, MPH (Boston University Schools of Medicine and Public Health; Associate Editor, JAMA), for his content expertise and review of the draft report; Meghan Soulsby Weyrich, MPH (University of California Davis, Center for Healthcare Policy and Research), for her assistance in data abstraction; and Smyth Lai, MLS, and Katherine Essick, BS (Kaiser Permanente Center for Health Research), for technical and editorial assistance. USPSTF members did not receive financial compensation for their contributions.

Additional Information: A draft version of the full evidence report underwent external peer review from 5 content experts (Michael Fleming, MD, MPH, Northwestern University; John Higgins-Biddle, PhD, University of Connecticut; Alison Moore, MD, MPH, University of California San Diego; Emily E. Tanner-Smith, PhD, University of Oregon; Michael Weaver, MD, University of Texas) and 9 federal partner reviewers from the National Institute of Alcohol Abuse and Alcoholism, National Institute of Mental Health, Office of Research on Women’s Health, National Center of Birth Defects and Developmental Disabilities, and the National Institute of Dental and Craniofacial Research. Comments from reviewers were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review. Peer reviewers and those commenting on behalf of partner organizations did not receive financial compensation for their contributions.

Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA.

References
1.
Mokdad  AH, Marks  JS, Stroup  DF, Gerberding  JL.  Actual causes of death in the United States, 2000.  JAMA. 2004;291(10):1238-1245. doi:10.1001/jama.291.10.1238PubMedGoogle ScholarCrossref
2.
Stahre  M, Roeber  J, Kanny  D, Brewer  RD, Zhang  X.  Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States.  Prev Chronic Dis. 2014;11:E109. doi:10.5888/pcd11.130293PubMedGoogle ScholarCrossref
3.
Center for Behavioral Health Statistics and Quality. Results from the 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf. 2017. Accessed October 2, 2017.
4.
Rehm  J, Gmel  GE  Sr, Gmel  G,  et al.  The relationship between different dimensions of alcohol use and the burden of disease—an update.  Addiction. 2017;112(6):968-1001. doi:10.1111/add.13757PubMedGoogle ScholarCrossref
5.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Harmful Interactions: Mixing Alcohol With Medicines. NIAAA website. https://pubs.niaaa.nih.gov/publications/Medicine/Harmful_Interactions.pdf. Published 2014. Accessed August 2, 2018.
6.
Moyer  VA; Preventive Services Task Force.  Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement.  Ann Intern Med. 2013;159(3):210-218.PubMedGoogle Scholar
7.
U.S. Preventive Services Task Force.  U.S. Preventive Services Task Force Procedure Manual. Rockville, MD: Agency for Healthcare Research and Quality; 2015.
8.
United Nations Development Programme (UNDP). Human Development Report 2015: Work for Human Development. UNDP website. http://hdr.undp.org/sites/default/files/2015_human_development_report_1.pdf. Published 2015. Accessed January, 2016.
9.
Whiting  PF, Rutjes  AW, Westwood  ME,  et al; QUADAS-2 Group.  QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies.  Ann Intern Med. 2011;155(8):529-536. doi:10.7326/0003-4819-155-8-201110180-00009PubMedGoogle ScholarCrossref
10.
DerSimonian  R, Kacker  R.  Random-effects model for meta-analysis of clinical trials: an update.  Contemp Clin Trials. 2007;28(2):105-114. doi:10.1016/j.cct.2006.04.004PubMedGoogle ScholarCrossref
11.
Egger  M, Davey Smith  G, Schneider  M, Minder  C.  Bias in meta-analysis detected by a simple, graphical test.  BMJ. 1997;315(7109):629-634. doi:10.1136/bmj.315.7109.629PubMedGoogle ScholarCrossref
12.
Aalto  M, Alho  H, Halme  JT, Seppä  K.  AUDIT and its abbreviated versions in detecting heavy and binge drinking in a general population survey.  Drug Alcohol Depend. 2009;103(1-2):25-29. doi:10.1016/j.drugalcdep.2009.02.013PubMedGoogle ScholarCrossref
13.
Aalto  M, Alho  H, Halme  JT, Seppä  K.  The Alcohol Use Disorders Identification Test (AUDIT) and its derivatives in screening for heavy drinking among the elderly.  Int J Geriatr Psychiatry. 2011;26(9):881-885. doi:10.1002/gps.2498PubMedGoogle ScholarCrossref
14.
Aertgeerts  B, Buntinx  F, Bande-Knops  J,  et al.  The value of CAGE, CUGE, and AUDIT in screening for alcohol abuse and dependence among college freshmen.  Alcohol Clin Exp Res. 2000;24(1):53-57. doi:10.1111/j.1530-0277.2000.tb04553.xPubMedGoogle ScholarCrossref
15.
Bartoli  F, Crocamo  C, Biagi  E,  et al.  Clinical utility of a single-item test for DSM-5 alcohol use disorder among outpatients with anxiety and depressive disorders.  Drug Alcohol Depend. 2016;165:283-287. doi:10.1016/j.drugalcdep.2016.06.003PubMedGoogle ScholarCrossref
16.
Boschloo  L, Vogelzangs  N, Smit  JH,  et al.  The performance of the Alcohol Use Disorder Identification Test (AUDIT) in detecting alcohol abuse and dependence in a population of depressed or anxious persons.  J Affect Disord. 2010;126(3):441-446. doi:10.1016/j.jad.2010.04.019PubMedGoogle ScholarCrossref
17.
Bradley  KA, Bush  KR, Epler  AJ,  et al.  Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population.  Arch Intern Med. 2003;163(7):821-829. doi:10.1001/archinte.163.7.821PubMedGoogle ScholarCrossref
18.
Buchsbaum  DG, Welsh  J, Buchanan  RG, Elswick  RK  Jr.  Screening for drinking problems by patient self-report: even “safe” levels may indicate a problem.  Arch Intern Med. 1995;155(1):104-108. doi:10.1001/archinte.1995.00430010112015PubMedGoogle ScholarCrossref
19.
Bull  LB, Kvigne  VL, Leonardson  GR, Lacina  L, Welty  TK.  Validation of a self-administered questionnaire to screen for prenatal alcohol use in Northern Plains Indian women.  Am J Prev Med. 1999;16(3):240-243. doi:10.1016/S0749-3797(98)00158-5PubMedGoogle ScholarCrossref
20.
Chung  T, Smith  GT, Donovan  JE,  et al.  Drinking frequency as a brief screen for adolescent alcohol problems.  Pediatrics. 2012;129(2):205-212. doi:10.1542/peds.2011-1828PubMedGoogle ScholarCrossref
21.
Clark  DB, Martin  CS, Chung  T,  et al.  Screening for underage drinking and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition alcohol use disorder in rural primary care practice.  J Pediatr. 2016;173:214-220.Google Scholar
22.
Clements  R.  A critical evaluation of several alcohol screening instruments using the CIDI-SAM as a criterion measure.  Alcohol Clin Exp Res. 1998;22(5):985-993. doi:10.1111/j.1530-0277.1998.tb03693.xPubMedGoogle ScholarCrossref
23.
Cook  RL, Chung  T, Kelly  TM, Clark  DB.  Alcohol screening in young persons attending a sexually transmitted disease clinic: comparison of AUDIT, CRAFFT, and CAGE instruments.  J Gen Intern Med. 2005;20(1):1-6. doi:10.1111/j.1525-1497.2005.40052.xPubMedGoogle ScholarCrossref
24.
Crawford  EF, Fulton  JJ, Swinkels  CM, Beckham  JC, Calhoun  PS; VA Mid-Atlantic MIRECC OEF/OIF Registry Workgroup.  Diagnostic efficiency of the AUDIT-C in U.S. veterans with military service since September 11, 2001.  Drug Alcohol Depend. 2013;132(1-2):101-106. doi:10.1016/j.drugalcdep.2013.01.012PubMedGoogle ScholarCrossref
25.
D’Amico  EJ, Parast  L, Meredith  LS, Ewing  BA, Shadel  WG, Stein  BD.  Screening in primary care: what is the best way to identify at-risk youth for substance use?  Pediatrics. 2016;138(6):e20161717. doi:10.1542/peds.2016-1717PubMedGoogle ScholarCrossref
26.
Dawson  DA, Grant  BF, Stinson  FS, Zhou  Y.  Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population.  Alcohol Clin Exp Res. 2005;29(5):844-854. doi:10.1097/01.ALC.0000164374.32229.A2PubMedGoogle ScholarCrossref
27.
Dawson  DA, Smith  SM, Saha  TD, Rubinsky  AD, Grant  BF.  Comparative performance of the AUDIT-C in screening for DSM-IV and DSM-5 alcohol use disorders.  Drug Alcohol Depend. 2012;126(3):384-388. doi:10.1016/j.drugalcdep.2012.05.029PubMedGoogle ScholarCrossref
28.
Degenhardt  LJ, Conigrave  KM, Wutzke  SE, Saunders  JB.  The validity of an Australian modification of the AUDIT questionnaire.  Drug Alcohol Rev. 2001;20(2):143-154. doi:10.1080/09595230124592Google ScholarCrossref
29.
Demartini  KS, Carey  KB.  Optimizing the use of the AUDIT for alcohol screening in college students.  Psychol Assess. 2012;24(4):954-963. doi:10.1037/a0028519PubMedGoogle ScholarCrossref
30.
Foxcroft  DR, Smith  LA, Thomas  H, Howcutt  S.  Accuracy of Alcohol Use Disorders Identification Test for detecting problem drinking in 18-35 year-olds in England: method comparison study.  Alcohol Alcohol. 2015;50(2):244-250. doi:10.1093/alcalc/agu095PubMedGoogle ScholarCrossref
31.
Gache  P, Michaud  P, Landry  U,  et al.  The Alcohol Use Disorders Identification Test (AUDIT) as a screening tool for excessive drinking in primary care: reliability and validity of a French version.  Alcohol Clin Exp Res. 2005;29(11):2001-2007. doi:10.1097/01.alc.0000187034.58955.64PubMedGoogle ScholarCrossref
32.
Gómez  A, Conde  A, Santana  JM, Jorrín  A.  Diagnostic usefulness of brief versions of Alcohol Use Disorders Identification Test (AUDIT) for detecting hazardous drinkers in primary care settings.  J Stud Alcohol. 2005;66(2):305-308. doi:10.15288/jsa.2005.66.305PubMedGoogle ScholarCrossref
33.
Gómez  A, Conde  A, Santana  JM, Jorrín  A, Serrano  IM, Medina  R.  The diagnostic usefulness of AUDIT and AUDIT-C for detecting hazardous drinkers in the elderly.  Aging Ment Health. 2006;10(5):558-561. doi:10.1080/13607860600637729PubMedGoogle ScholarCrossref
34.
Gryczynski  J, Kelly  SM, Mitchell  SG, Kirk  A, O’Grady  KE, Schwartz  RP.  Validation and performance of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) among adolescent primary care patients.  Addiction. 2015;110(2):240-247. doi:10.1111/add.12767PubMedGoogle ScholarCrossref
35.
Gual  A, Segura  L, Contel  M, Heather  N, Colom  J.  AUDIT-3 and AUDIT-4: effectiveness of two short forms of the Alcohol Use Disorders Identification Test.  Alcohol Alcohol. 2002;37(6):591-596. doi:10.1093/alcalc/37.6.591PubMedGoogle ScholarCrossref
36.
Harris  SK, Knight  JR  Jr, Van Hook  S,  et al.  Adolescent substance use screening in primary care: validity of computer self-administered versus clinician-administered screening.  Subst Abus. 2016;37(1):197-203. doi:10.1080/08897077.2015.1014615PubMedGoogle ScholarCrossref
37.
Isaacson  JH, Butler  R, Zacharek  M, Tzelepis  A.  Screening with the Alcohol use Disorders Identification Test (AUDIT) in an inner-city population.  J Gen Intern Med. 1994;9(10):550-553. doi:10.1007/BF02599279PubMedGoogle ScholarCrossref
38.
Kelly  SM, Gryczynski  J, Mitchell  SG, Kirk  A, O’Grady  KE, Schwartz  RP.  Validity of brief screening instrument for adolescent tobacco, alcohol, and drug use.  Pediatrics. 2014;133(5):819-826. doi:10.1542/peds.2013-2346PubMedGoogle ScholarCrossref
39.
Knight  JR, Sherritt  L, Harris  SK, Gates  EC, Chang  G.  Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT.  Alcohol Clin Exp Res. 2003;27(1):67-73. doi:10.1111/j.1530-0277.2003.tb02723.xPubMedGoogle ScholarCrossref
40.
Kokotailo  PK, Egan  J, Gangnon  R, Brown  D, Mundt  M, Fleming  M.  Validity of the Alcohol Use Disorders Identification Test in college students.  Alcohol Clin Exp Res. 2004;28(6):914-920. doi:10.1097/01.ALC.0000128239.87611.F5PubMedGoogle ScholarCrossref
41.
Kumar  PC, Cleland  CM, Gourevitch  MN,  et al.  Accuracy of the Audio Computer Assisted Self Interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ACASI ASSIST) for identifying unhealthy substance use and substance use disorders in primary care patients.  Drug Alcohol Depend. 2016;165:38-44. doi:10.1016/j.drugalcdep.2016.05.030PubMedGoogle ScholarCrossref
42.
Levola  J, Aalto  M.  Screening for at-risk drinking in a population reporting symptoms of depression: a validation of the AUDIT, AUDIT-C, and AUDIT-3.  Alcohol Clin Exp Res. 2015;39(7):1186-1192. doi:10.1111/acer.12763PubMedGoogle ScholarCrossref
43.
Levy  S, Dedeoglu  F, Gaffin  JM,  et al.  A screening tool for assessing alcohol use risk among medically vulnerable youth.  PLoS One. 2016;11(5):e0156240. doi:10.1371/journal.pone.0156240PubMedGoogle ScholarCrossref
44.
McCann  BS, Simpson  TL, Ries  R, Roy-Byrne  P.  Reliability and validity of screening instruments for drug and alcohol abuse in adults seeking evaluation for attention-deficit/hyperactivity disorder.  Am J Addict. 2000;9(1):1-9. doi:10.1080/10550490050172173PubMedGoogle ScholarCrossref
45.
McGinnis  KA, Justice  AC, Kraemer  KL, Saitz  R, Bryant  KJ, Fiellin  DA.  Comparing alcohol screening measures among HIV-infected and -uninfected men.  Alcohol Clin Exp Res. 2013;37(3):435-442. doi:10.1111/j.1530-0277.2012.01937.xPubMedGoogle ScholarCrossref
46.
McNeely  J, Strauss  SM, Saitz  R,  et al.  A brief patient self-administered substance use screening tool for primary care: two-site validation study of the Substance Use Brief Screen (SUBS).  Am J Med. 2015;128(7):784.e9-784.e19. doi:10.1016/j.amjmed.2015.02.007PubMedGoogle ScholarCrossref
47.
Northrup  TF, Malone  PS, Follingstad  D, Stotts  AL.  Using item response theory to improve alcohol dependence screening for African American and white male and female college students.  Addict Disord Their Treat. 2013;12(2):99-109. doi:10.1097/ADT.0b013e3182627431Google ScholarCrossref
48.
Piccinelli  M, Tessari  E, Bortolomasi  M,  et al.  Efficacy of the Alcohol Use Disorders Identification Test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study.  BMJ. 1997;314(7078):420-424. doi:10.1136/bmj.314.7078.420PubMedGoogle ScholarCrossref
49.
Rumpf  HJ, Hapke  U, Meyer  C, John  U.  Screening for alcohol use disorders and at-risk drinking in the general population: psychometric performance of three questionnaires.  Alcohol Alcohol. 2002;37(3):261-268. doi:10.1093/alcalc/37.3.261PubMedGoogle ScholarCrossref
50.
Rumpf  HJ, Wohlert  T, Freyer-Adam  J, Grothues  J, Bischof  G.  Screening questionnaires for problem drinking in adolescents: performance of AUDIT, AUDIT-C, CRAFFT and POSIT.  Eur Addict Res. 2013;19(3):121-127. doi:10.1159/000342331PubMedGoogle ScholarCrossref
51.
Santis  R, Garmendia  ML, Acuña  G, Alvarado  ME, Arteaga  O.  The Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument for adolescents.  Drug Alcohol Depend. 2009;103(3):155-158. doi:10.1016/j.drugalcdep.2009.01.017PubMedGoogle ScholarCrossref
52.
Seale  JP, Boltri  JM, Shellenberger  S,  et al.  Primary care validation of a single screening question for drinkers.  J Stud Alcohol. 2006;67(5):778-784. doi:10.15288/jsa.2006.67.778PubMedGoogle ScholarCrossref
53.
Smith  PC, Schmidt  SM, Allensworth-Davies  D, Saitz  R.  Primary care validation of a single-question alcohol screening test  [published correction appears in J Gen Intern Med. 2010;25(4):375].  J Gen Intern Med. 2009;24(7):783-788. doi:10.1007/s11606-009-0928-6PubMedGoogle ScholarCrossref
54.
Volk  RJ, Steinbauer  JR, Cantor  SB, Holzer  CE  III.  The Alcohol Use Disorders Identification Test (AUDIT) as a screen for at-risk drinking in primary care patients of different racial/ethnic backgrounds.  Addiction. 1997;92(2):197-206. doi:10.1111/j.1360-0443.1997.tb03652.xPubMedGoogle ScholarCrossref
55.
López  MB, Lichtenberger  A, Conde  K, Cremonte  M.  Psychometric properties of brief screening tests for alcohol use disorders during pregnancy in Argentina  [in Portugese].  Rev Bras Ginecol Obstet. 2017;39(7):322-329. doi:10.1055/s-0037-1603744PubMedGoogle ScholarCrossref
56.
McNeely  J, Wu  LT, Subramaniam  G,  et al.  Performance of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool for substance use screening in primary care patients.  Ann Intern Med. 2016;165(10):690-699. doi:10.7326/M16-0317PubMedGoogle ScholarCrossref
57.
Bradley  KA, DeBenedetti  AF, Volk  RJ, Williams  EC, Frank  D, Kivlahan  DR.  AUDIT-C as a brief screen for alcohol misuse in primary care.  Alcohol Clin Exp Res. 2007;31(7):1208-1217. doi:10.1111/j.1530-0277.2007.00403.xPubMedGoogle ScholarCrossref
58.
Bush  KR, Kivlahan  DR, Davis  TM,  et al.  The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients.  Alcohol Clin Exp Res. 2003;27(12):1971-1978. doi:10.1097/01.ALC.0000099262.50094.98PubMedGoogle ScholarCrossref
59.
Dawson  DA, Pulay  AJ, Grant  BF.  A comparison of two single-item screeners for hazardous drinking and alcohol use disorder.  Alcohol Clin Exp Res. 2010;34(2):364-374. doi:10.1111/j.1530-0277.2009.01098.xPubMedGoogle ScholarCrossref
60.
Frank  D, DeBenedetti  AF, Volk  RJ, Williams  EC, Kivlahan  DR, Bradley  KA.  Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups.  J Gen Intern Med. 2008;23(6):781-787. doi:10.1007/s11606-008-0594-0PubMedGoogle ScholarCrossref
61.
Johnson  JA, Lee  A, Vinson  D, Seale  JP.  Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: a validation study.  Alcohol Clin Exp Res. 2013;37(suppl 1):E253-E259. doi:10.1111/j.1530-0277.2012.01898.xPubMedGoogle ScholarCrossref
62.
McNeely  J, Cleland  CM, Strauss  SM, Palamar  JJ, Rotrosen  J, Saitz  R.  Validation of self-administered Single-Item Screening Questions (SISQs) for unhealthy alcohol and drug use in primary care patients.  J Gen Intern Med. 2015;30(12):1757-1764. doi:10.1007/s11606-015-3391-6PubMedGoogle ScholarCrossref
63.
Northrup  TF.  Effective measurement of problematic drinking for college students: reducing differential item functioning across gender and race.  Diss Abstr Int B Sci Eng. 2010;70(7-B):4492.Google Scholar
64.
Saitz  R, Cheng  DM, Allensworth-Davies  D, Winter  MR, Smith  PC.  The ability of single screening questions for unhealthy alcohol and other drug use to identify substance dependence in primary care.  J Stud Alcohol Drugs. 2014;75(1):153-157. doi:10.15288/jsad.2014.75.153PubMedGoogle ScholarCrossref
65.
Steinbauer  JR, Cantor  SB, Holzer  CE  III, Volk  RJ.  Ethnic and sex bias in primary care screening tests for alcohol use disorders.  Ann Intern Med. 1998;129(5):353-362. doi:10.7326/0003-4819-129-5-199809010-00002PubMedGoogle ScholarCrossref
66.
Wu  LT, McNeely  J, Subramaniam  GA, Sharma  G, VanVeldhuisen  P, Schwartz  RP.  Design of the NIDA clinical trials network validation study of Tobacco, Alcohol, Prescription medications, and Substance use/misuse (TAPS) tool.  Contemp Clin Trials. 2016;50:90-97. doi:10.1016/j.cct.2016.07.013PubMedGoogle ScholarCrossref
67.
Gryczynski  J, McNeely  J, Wu  LT,  et al.  Validation of the TAPS-1: a four-item screening tool to identify unhealthy substance use in primary care.  J Gen Intern Med. 2017;32(9):990-996. doi:10.1007/s11606-017-4079-xPubMedGoogle ScholarCrossref
68.
Whiting  P, Rutjes  AW, Reitsma  JB, Bossuyt  PM, Kleijnen  J.  The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews.  BMC Med Res Methodol. 2003;3:25. doi:10.1186/1471-2288-3-25PubMedGoogle ScholarCrossref
69.
Whiting  P, Wolff  R.  Medical use of cannabinoids—reply.  JAMA. 2015;314(16):1751-1752. doi:10.1001/jama.2015.11447PubMedGoogle ScholarCrossref
70.
Aalto  M, Saksanen  R, Laine  P,  et al.  Brief intervention for female heavy drinkers in routine general practice: a 3-year randomized, controlled study.  Alcohol Clin Exp Res. 2000;24(11):1680-1686. doi:10.1111/j.1530-0277.2000.tb01969.xPubMedGoogle ScholarCrossref
71.
Bertholet  N, Cunningham  JA, Faouzi  M,  et al.  Internet-based brief intervention for young men with unhealthy alcohol use: a randomized controlled trial in a general population sample.  Addiction. 2015;110(11):1735-1743. doi:10.1111/add.13051PubMedGoogle ScholarCrossref
72.
Bischof  G, Grothues  JM, Reinhardt  S, Meyer  C, John  U, Rumpf  HJ.  Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: a randomized controlled trial.  Drug Alcohol Depend. 2008;93(3):244-251. doi:10.1016/j.drugalcdep.2007.10.003PubMedGoogle ScholarCrossref
73.
Burge  SK, Amodei  N, Elkin  B,  et al.  An evaluation of two primary care interventions for alcohol abuse among Mexican-American patients.  Addiction. 1997;92(12):1705-1716. doi:10.1111/j.1360-0443.1997.tb02891.xPubMedGoogle ScholarCrossref
74.
Butler  CC, Simpson  SA, Hood  K,  et al.  Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial.  BMJ. 2013;346:f1191. doi:10.1136/bmj.f1191PubMedGoogle ScholarCrossref
75.
Carey  KB, Carey  MP, Maisto  SA, Henson  JM.  Brief motivational interventions for heavy college drinkers: a randomized controlled trial.  J Consult Clin Psychol. 2006;74(5):943-954. doi:10.1037/0022-006X.74.5.943PubMedGoogle ScholarCrossref
76.
Chang  G, Fisher  ND, Hornstein  MD,  et al.  Brief intervention for women with risky drinking and medical diagnoses: a randomized controlled trial.  J Subst Abuse Treat. 2011;41(2):105-114. doi:10.1016/j.jsat.2011.02.011PubMedGoogle ScholarCrossref
77.
Chang  G, McNamara  TK, Orav  EJ,  et al.  Brief intervention for prenatal alcohol use: a randomized trial.  Obstet Gynecol. 2005;105(5, pt 1):991-998. doi:10.1097/01.AOG.0000157109.05453.84PubMedGoogle ScholarCrossref
78.
Chang  G, Wilkins-Haug  L, Berman  S, Goetz  MA.  Brief intervention for alcohol use in pregnancy: a randomized trial.  Addiction. 1999;94(10):1499-1508. doi:10.1046/j.1360-0443.1999.941014996.xPubMedGoogle ScholarCrossref
79.
Collins  SE, Kirouac  M, Lewis  MA, Witkiewitz  K, Carey  KB.  Randomized controlled trial of web-based decisional balance feedback and personalized normative feedback for college drinkers.  J Stud Alcohol Drugs. 2014;75(6):982-992. doi:10.15288/jsad.2014.75.982PubMedGoogle ScholarCrossref
80.
Crawford  MJ, Sanatinia  R, Barrett  B,  et al.  The clinical effectiveness and cost-effectiveness of brief intervention for excessive alcohol consumption among people attending sexual health clinics: a randomised controlled trial (SHEAR).  Health Technol Assess. 2014;18(30):1-48. doi:10.3310/hta18300PubMedGoogle ScholarCrossref
81.
Cunningham  JA, Neighbors  C, Wild  C, Humphreys  K.  Ultra-brief intervention for problem drinkers: results from a randomized controlled trial.  PLoS One. 2012;7(10):e48003. doi:10.1371/journal.pone.0048003PubMedGoogle ScholarCrossref
82.
Curry  SJ, Ludman  EJ, Grothaus  LC, Donovan  D, Kim  E.  A randomized trial of a brief primary-care-based intervention for reducing at-risk drinking practices.  Health Psychol. 2003;22(2):156-165. doi:10.1037/0278-6133.22.2.156PubMedGoogle ScholarCrossref
83.
Daeppen  JB, Bertholet  N, Gaume  J, Fortini  C, Faouzi  M, Gmel  G.  Efficacy of brief motivational intervention in reducing binge drinking in young men: a randomized controlled trial.  Drug Alcohol Depend. 2011;113(1):69-75. doi:10.1016/j.drugalcdep.2010.07.009PubMedGoogle ScholarCrossref
84.
Drummond  C, Coulton  S, James  D,  et al.  Effectiveness and cost-effectiveness of a stepped care intervention for alcohol use disorders in primary care: pilot study.  Br J Psychiatry. 2009;195(5):448-456. doi:10.1192/bjp.bp.108.056697PubMedGoogle ScholarCrossref
85.
Emmen  MJ, Schippers  GM, Wollersheim  H, Bleijenberg  G.  Adding psychologist’s intervention to physicians’ advice to problem drinkers in the outpatient clinic.  Alcohol Alcohol. 2005;40(3):219-226. doi:10.1093/alcalc/agh137PubMedGoogle ScholarCrossref
86.
Ettner  SL, Xu  H, Duru  OK,  et al.  The effect of an educational intervention on alcohol consumption, at-risk drinking, and health care utilization in older adults: the Project SHARE study.  J Stud Alcohol Drugs. 2014;75(3):447-457. doi:10.15288/jsad.2014.75.447PubMedGoogle ScholarCrossref
87.
Fleming  MF, Balousek  SL, Grossberg  PM,  et al.  Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics.  J Stud Alcohol Drugs. 2010;71(1):23-31. doi:10.15288/jsad.2010.71.23PubMedGoogle ScholarCrossref
88.
Fleming  MF, Barry  KL, Manwell  LB, Johnson  K, London  R.  Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices.  JAMA. 1997;277(13):1039-1045. doi:10.1001/jama.1997.03540370029032PubMedGoogle ScholarCrossref
89.
Fleming  MF, Lund  MR, Wilton  G, Landry  M, Scheets  D.  The Healthy Moms Study: the efficacy of brief alcohol intervention in postpartum women.  Alcohol Clin Exp Res. 2008;32(9):1600-1606. doi:10.1111/j.1530-0277.2008.00738.xPubMedGoogle ScholarCrossref
90.
Fleming  MF, Manwell  LB, Barry  KL, Adams  W, Stauffacher  EA.  Brief physician advice for alcohol problems in older adults: a randomized community-based trial.  J Fam Pract. 1999;48(5):378-384.PubMedGoogle Scholar
91.
Hansen  AB, Becker  U, Nielsen  AS, Grønbæk  M, Tolstrup  JS, Thygesen  LC.  Internet-based brief personalized feedback intervention in a non-treatment-seeking population of adult heavy drinkers: a randomized controlled trial.  J Med Internet Res. 2012;14(4):e98. doi:10.2196/jmir.1883PubMedGoogle ScholarCrossref
92.
Haug  S, Paz Castro  R, Kowatsch  T, Filler  A, Dey  M, Schaub  MP.  Efficacy of a web- and text messaging-based intervention to reduce problem drinking in adolescents: results of a cluster-randomized controlled trial.  J Consult Clin Psychol. 2017;85(2):147-159. doi:10.1037/ccp0000138PubMedGoogle ScholarCrossref
93.
Heather  N, Campion  PD, Neville  RG, Maccabe  D.  Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS scheme).  J R Coll Gen Pract. 1987;37(301):358-363.PubMedGoogle Scholar
94.
Helstrom  AW, Ingram  E, Wang  W, Small  D, Klaus  J, Oslin  D.  Treating heavy drinking in primary care practices: evaluation of a telephone-based intervention program.  Addict Disord Their Treat. 2014;13(3):101-109. doi:10.1097/ADT.0b013e31827e206cGoogle ScholarCrossref
95.
Hilbink  M, Voerman  G, van Beurden  I, Penninx  B, Laurant  M.  A randomized controlled trial of a tailored primary care program to reverse excessive alcohol consumption.  J Am Board Fam Med. 2012;25(5):712-722. doi:10.3122/jabfm.2012.05.120070PubMedGoogle ScholarCrossref
96.
Johnsson  KO, Berglund  M.  Comparison between a cognitive behavioural alcohol programme and post-mailed minimal intervention in high-risk drinking university freshmen: results from a randomized controlled trial.  Alcohol Alcohol. 2006;41(2):174-180. doi:10.1093/alcalc/agh243PubMedGoogle ScholarCrossref
97.
Kaner  E, Bland  M, Cassidy  P,  et al.  Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial.  BMJ. 2013;346:e8501. doi:10.1136/bmj.e8501PubMedGoogle ScholarCrossref
98.
Kypri  K, Hallett  J, Howat  P,  et al.  Randomized controlled trial of proactive web-based alcohol screening and brief intervention for university students.  Arch Intern Med. 2009;169(16):1508-1514. doi:10.1001/archinternmed.2009.249PubMedGoogle ScholarCrossref
99.
Kypri  K, Langley  JD, Saunders  JB, Cashell-Smith  ML, Herbison  P.  Randomized controlled trial of web-based alcohol screening and brief intervention in primary care.  Arch Intern Med. 2008;168(5):530-536. doi:10.1001/archinternmed.2007.109PubMedGoogle ScholarCrossref
100.
Kypri  K, Saunders  JB, Williams  SM,  et al.  Web-based screening and brief intervention for hazardous drinking: a double-blind randomized controlled trial.  Addiction. 2004;99(11):1410-1417. doi:10.1111/j.1360-0443.2004.00847.xPubMedGoogle ScholarCrossref
101.
LaBrie  JW, Huchting  KK, Lac  A, Tawalbeh  S, Thompson  AD, Larimer  ME.  Preventing risky drinking in first-year college women: further validation of a female-specific motivational-enhancement group intervention.  J Stud Alcohol Drugs Suppl. 2009;(16):77-85. doi:10.15288/jsads.2009.s16.77PubMedGoogle Scholar
102.
Labrie  JW, Lewis  MA, Atkins  DC,  et al.  RCT of web-based personalized normative feedback for college drinking prevention: are typical student norms good enough?  J Consult Clin Psychol. 2013;81(6):1074-1086. doi:10.1037/a0034087PubMedGoogle ScholarCrossref
103.
Larimer  ME, Lee  CM, Kilmer  JR,  et al.  Personalized mailed feedback for college drinking prevention: a randomized clinical trial.  J Consult Clin Psychol. 2007;75(2):285-293. doi:10.1037/0022-006X.75.2.285PubMedGoogle ScholarCrossref
104.
Leeman  RF, DeMartini  KS, Gueorguieva  R,  et al.  Randomized controlled trial of a very brief, multicomponent web-based alcohol intervention for undergraduates with a focus on protective behavioral strategies.  J Consult Clin Psychol. 2016;84(11):1008-1015. doi:10.1037/ccp0000132PubMedGoogle ScholarCrossref
105.
Lewis  MA, Patrick  ME, Litt  DM,  et al.  Randomized controlled trial of a web-delivered personalized normative feedback intervention to reduce alcohol-related risky sexual behavior among college students.  J Consult Clin Psychol. 2014;82(3):429-440. doi:10.1037/a0035550PubMedGoogle ScholarCrossref
106.
Maisto  SA, Conigliaro  J, McNeil  M, Kraemer  K, Conigliaro  RL, Kelley  ME.  Effects of two types of brief intervention and readiness to change on alcohol use in hazardous drinkers.  J Stud Alcohol. 2001;62(5):605-614. doi:10.15288/jsa.2001.62.605PubMedGoogle ScholarCrossref
107.
Marlatt  GA, Baer  JS, Kivlahan  DR,  et al.  Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment.  J Consult Clin Psychol. 1998;66(4):604-615. doi:10.1037/0022-006X.66.4.604PubMedGoogle ScholarCrossref
108.
Martens  MP, Kilmer  JR, Beck  NC, Zamboanga  BL.  The efficacy of a targeted personalized drinking feedback intervention among intercollegiate athletes: a randomized controlled trial.  Psychol Addict Behav. 2010;24(4):660-669. doi:10.1037/a0020299PubMedGoogle ScholarCrossref
109.
Mason  M, Light  J, Campbell  L,  et al.  Peer network counseling with urban adolescents: a randomized controlled trial with moderate substance users.  J Subst Abuse Treat. 2015;58:16-24. doi:10.1016/j.jsat.2015.06.013PubMedGoogle ScholarCrossref
110.
Moore  AA, Blow  FC, Hoffing  M,  et al.  Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial.  Addiction. 2011;106(1):111-120. doi:10.1111/j.1360-0443.2010.03229.xPubMedGoogle ScholarCrossref
111.
Neighbors  C, Larimer  ME, Lewis  MA.  Targeting misperceptions of descriptive drinking norms: efficacy of a computer-delivered personalized normative feedback intervention.  J Consult Clin Psychol. 2004;72(3):434-447. doi:10.1037/0022-006X.72.3.434PubMedGoogle ScholarCrossref
112.
Neighbors  C, Lewis  MA, Atkins  DC,  et al.  Efficacy of web-based personalized normative feedback: a two-year randomized controlled trial.  J Consult Clin Psychol. 2010;78(6):898-911. doi:10.1037/a0020766PubMedGoogle ScholarCrossref
113.
Neighbors  C, Lewis  MA, LaBrie  J,  et al.  A multisite randomized trial of normative feedback for heavy drinking: social comparison versus social comparison plus correction of normative misperceptions.  J Consult Clin Psychol. 2016;84(3):238-247. doi:10.1037/ccp0000067PubMedGoogle ScholarCrossref
114.
Ockene  JK, Adams  A, Hurley  TG, Wheeler  EV, Hebert  JR.  Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work?  Arch Intern Med. 1999;159(18):2198-2205. doi:10.1001/archinte.159.18.2198PubMedGoogle ScholarCrossref
115.
O’Connor  MJ, Whaley  SE.  Brief intervention for alcohol use by pregnant women.  Am J Public Health. 2007;97(2):252-258. doi:10.2105/AJPH.2005.077222PubMedGoogle ScholarCrossref
116.
Ondersma  SJ, Beatty  JR, Svikis  DS,  et al.  Computer-delivered screening and brief intervention for alcohol use in pregnancy: a pilot randomized trial.  Alcohol Clin Exp Res. 2015;39(7):1219-1226. doi:10.1111/acer.12747PubMedGoogle ScholarCrossref
117.
Ondersma  SJ, Svikis  DS, Thacker  LR, Beatty  JR, Lockhart  N.  A randomised trial of a computer-delivered screening and brief intervention for postpartum alcohol use.  Drug Alcohol Rev. 2016;35(6):710-718. doi:10.1111/dar.12389PubMedGoogle ScholarCrossref
118.
Osterman  RL, Carle  AC, Ammerman  RT, Gates  D.  Single-session motivational intervention to decrease alcohol use during pregnancy.  J Subst Abuse Treat. 2014;47(1):10-19. doi:10.1016/j.jsat.2014.01.009PubMedGoogle ScholarCrossref
119.
Reynolds  KD, Coombs  DW, Lowe  JB, Peterson  PL, Gayoso  E.  Evaluation of a self-help program to reduce alcohol consumption among pregnant women.  Int J Addict. 1995;30(4):427-443. doi:10.3109/10826089509048735PubMedGoogle ScholarCrossref
120.
Richmond  R, Heather  N, Wodak  A, Kehoe  L, Webster  I.  Controlled evaluation of a general practice-based brief intervention for excessive drinking.  Addiction. 1995;90(1):119-132. doi:10.1111/j.1360-0443.1995.tb01016.xPubMedGoogle ScholarCrossref
121.
Rose  GL, Badger  GJ, Skelly  JM, MacLean  CD, Ferraro  TA, Helzer  JE.  A randomized controlled trial of brief intervention by interactive voice response.  Alcohol Alcohol. 2017;52(3):335-343.PubMedGoogle Scholar
122.
Rubio  DM, Day  NL, Conigliaro  J,  et al.  Brief motivational enhancement intervention to prevent or reduce postpartum alcohol use: a single-blinded, randomized controlled effectiveness trial.  J Subst Abuse Treat. 2014;46(3):382-389. doi:10.1016/j.jsat.2013.10.009PubMedGoogle ScholarCrossref
123.
Rubio  G, Jiménez-Arriero  MA, Martínez  I, Ponce  G, Palomo  T.  Efficacy of physician-delivered brief counseling intervention for binge drinkers.  Am J Med. 2010;123(1):72-78. doi:10.1016/j.amjmed.2009.08.012PubMedGoogle ScholarCrossref
124.
Saitz  R, Horton  NJ, Sullivan  LM, Moskowitz  MA, Samet  JH.  Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention: the screening and intervention in primary care (SIP) study.  Ann Intern Med. 2003;138(5):372-382. doi:10.7326/0003-4819-138-5-200303040-00006PubMedGoogle ScholarCrossref
125.
Schaus  JF, Sole  ML, McCoy  TP, Mullett  N, O’Brien  MC.  Alcohol screening and brief intervention in a college student health center: a randomized controlled trial.  J Stud Alcohol Drugs Suppl. 2009;(16):131-141. doi:10.15288/jsads.2009.s16.131PubMedGoogle Scholar
126.
Schulz  DN, Candel  MJ, Kremers  SP, Reinwand  DA, Jander  A, de Vries  H.  Effects of a web-based tailored intervention to reduce alcohol consumption in adults: randomized controlled trial.  J Med Internet Res. 2013;15(9):e206. doi:10.2196/jmir.2568PubMedGoogle ScholarCrossref
127.
Scott  E, Anderson  P.  Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption.  Drug Alcohol Rev. 1991;10(4):313-321. doi:10.1080/09595239100185371PubMedGoogle ScholarCrossref
128.
Senft  RA, Polen  MR, Freeborn  DK, Hollis  JF.  Brief intervention in a primary care setting for hazardous drinkers.  Am J Prev Med. 1997;13(6):464-470. doi:10.1016/S0749-3797(18)30143-0PubMedGoogle ScholarCrossref
129.
Turrisi  R, Larimer  ME, Mallett  KA,  et al.  A randomized clinical trial evaluating a combined alcohol intervention for high-risk college students.  J Stud Alcohol Drugs. 2009;70(4):555-567. doi:10.15288/jsad.2009.70.555PubMedGoogle ScholarCrossref
130.
Tzilos  GK, Sokol  RJ, Ondersma  SJ.  A randomized phase I trial of a brief computer-delivered intervention for alcohol use during pregnancy.  J Womens Health (Larchmt). 2011;20(10):1517-1524. doi:10.1089/jwh.2011.2732PubMedGoogle ScholarCrossref
131.
Upshur  C, Weinreb  L, Bharel  M, Reed  G, Frisard  C.  A randomized control trial of a chronic care intervention for homeless women with alcohol use problems.  J Subst Abuse Treat. 2015;51:19-29. doi:10.1016/j.jsat.2014.11.001PubMedGoogle ScholarCrossref
132.
van der Wulp  NY, Hoving  C, Eijmael  K, Candel  MJ, van Dalen  W, De Vries  H.  Reducing alcohol use during pregnancy via health counseling by midwives and internet-based computer-tailored feedback: a cluster randomized trial.  J Med Internet Res. 2014;16(12):e274. doi:10.2196/jmir.3493PubMedGoogle ScholarCrossref
133.
Voogt  CV, Kuntsche  E, Kleinjan  M, Engels  RC.  The effect of the “What Do You Drink” web-based brief alcohol intervention on self-efficacy to better understand changes in alcohol use over time: randomized controlled trial using ecological momentary assessment.  Drug Alcohol Depend. 2014;138:89-97. doi:10.1016/j.drugalcdep.2014.02.009PubMedGoogle ScholarCrossref
134.
Wallace  P, Cutler  S, Haines  A.  Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption.  BMJ. 1988;297(6649):663-668. doi:10.1136/bmj.297.6649.663PubMedGoogle ScholarCrossref
135.
Watkins  KE, Ober  AJ, Lamp  K,  et al.  Collaborative care for opioid and alcohol use disorders in primary care: the SUMMIT randomized clinical trial.  JAMA Intern Med. 2017;177(10):1480-1488. doi:10.1001/jamainternmed.2017.3947PubMedGoogle ScholarCrossref
136.
Watson  JM, Crosby  H, Dale  VM,  et al; AESOPS Trial Team.  AESOPS: a randomised controlled trial of the clinical effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care.  Health Technol Assess. 2013;17(25):1-158. doi:10.3310/hta17250PubMedGoogle ScholarCrossref
137.
Wilson  GB, Wray  C, McGovern  R,  et al.  Intervention to reduce excessive alcohol consumption and improve comorbidity outcomes in hypertensive or depressed primary care patients: two parallel cluster randomized feasibility trials.  Trials. 2014;15:235. doi:10.1186/1745-6215-15-235PubMedGoogle ScholarCrossref
138.
Aalto  M, Seppä  K, Mattila  P,  et al.  Brief intervention for male heavy drinkers in routine general practice: a three-year randomized controlled study.  Alcohol Alcohol. 2001;36(3):224-230. doi:10.1093/alcalc/36.3.224PubMedGoogle ScholarCrossref
139.
Anderson  P, Scott  E.  The effect of general practitioners’ advice to heavy drinking men.  Br J Addict. 1992;87(6):891-900. doi:10.1111/j.1360-0443.1992.tb01984.xPubMedGoogle ScholarCrossref
140.
Baer  JS, Kivlahan  DR, Blume  AW, McKnight  P, Marlatt  GA.  Brief intervention for heavy-drinking college students: 4-year follow-up and natural history.  Am J Public Health. 2001;91(8):1310-1316. doi:10.2105/AJPH.91.8.1310PubMedGoogle ScholarCrossref
141.
Barnes  AJ, Xu  H, Tseng  CH,  et al.  The effect of a patient-provider educational intervention to reduce at-risk drinking on changes in health and health-related quality of life among older adults: the Project SHARE study.  J Subst Abuse Treat. 2016;60:14-20. doi:10.1016/j.jsat.2015.06.019PubMedGoogle ScholarCrossref
142.
Cleveland  MJ, Lanza  ST, Ray  AE, Turrisi  R, Mallett  KA.  Transitions in first-year college student drinking behaviors: does pre-college drinking moderate the effects of parent- and peer-based intervention components?  Psychol Addict Behav. 2012;26(3):440-450. doi:10.1037/a0026130PubMedGoogle ScholarCrossref
143.
Coulton  S, Bland  M, Crosby  H,  et al.  Effectiveness and cost-effectiveness of opportunistic screening and stepped-care interventions for older alcohol users in primary care.  Alcohol Alcohol. 2017;52(6):655-664. doi:10.1093/alcalc/agx065PubMedGoogle ScholarCrossref
144.
Coulton  S, Dale  V, Deluca  P,  et al.  Screening for at-risk alcohol consumption in primary care: a randomized evaluation of screening approaches.  Alcohol Alcohol. 2017;52(3):312-317. doi:10.1093/alcalc/agx017PubMedGoogle ScholarCrossref
145.
Crawford  MJ, Sanatinia  R, Barrett  B,  et al.  The clinical and cost-effectiveness of brief advice for excessive alcohol consumption among people attending sexual health clinics: a randomised controlled trial.  Sex Transm Infect. 2015;91(1):37-43. doi:10.1136/sextrans-2014-051561PubMedGoogle ScholarCrossref
146.
Fleming  MF, Mundt  MP, French  MT, Manwell  LB, Stauffacher  EA, Barry  KL.  Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings.  Med Care. 2000;38(1):7-18. doi:10.1097/00005650-200001000-00003PubMedGoogle ScholarCrossref
147.
Fleming  MF, Mundt  MP, French  MT, Manwell  LB, Stauffacher  EA, Barry  KL.  Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis.  Alcohol Clin Exp Res. 2002;26(1):36-43. doi:10.1111/j.1530-0277.2002.tb02429.xPubMedGoogle ScholarCrossref
148.
Freeborn  DK, Polen  MR, Hollis  JF, Senft  RA.  Screening and brief intervention for hazardous drinking in an HMO: effects on medical care utilization.  J Behav Health Serv Res. 2000;27(4):446-453. doi:10.1007/BF02287826PubMedGoogle ScholarCrossref
149.
Gordon  AJ, Conigliaro  J, Maisto  SA, McNeil  M, Kraemer  KL, Kelley  ME.  Comparison of consumption effects of brief interventions for hazardous drinking elderly.  Subst Use Misuse. 2003;38(8):1017-1035. doi:10.1081/JA-120017649PubMedGoogle ScholarCrossref
150.
Grossbard  JR, Mastroleo  NR, Geisner  IM,  et al.  Drinking norms, readiness to change, and gender as moderators of a combined alcohol intervention for first-year college students.  Addict Behav. 2016;52:75-82. doi:10.1016/j.addbeh.2015.07.028PubMedGoogle ScholarCrossref
151.
Grossbard  JR, Mastroleo  NR, Kilmer  JR,  et al.  Substance use patterns among first-year college students: secondary effects of a combined alcohol intervention.  J Subst Abuse Treat. 2010;39(4):384-390. doi:10.1016/j.jsat.2010.07.001PubMedGoogle ScholarCrossref
152.
Grossberg  PM, Brown  DD, Fleming  MF.  Brief physician advice for high-risk drinking among young adults.  Ann Fam Med. 2004;2(5):474-480. doi:10.1370/afm.122PubMedGoogle ScholarCrossref
153.
Grothues  JM, Bischof  G, Reinhardt  S, Meyer  C, John  U, Rumpf  HJ.  Effectiveness of brief alcohol interventions for general practice patients with problematic drinking behavior and comorbid anxiety or depressive disorders.  Drug Alcohol Depend. 2008;94(1-3):214-220. doi:10.1016/j.drugalcdep.2007.11.015PubMedGoogle ScholarCrossref
154.
Kaner  E, Bland  M, Cassidy  P,  et al.  Screening and brief interventions for hazardous and harmful alcohol use in primary care: a cluster randomised controlled trial protocol.  BMC Public Health. 2009;9:287. doi:10.1186/1471-2458-9-287PubMedGoogle ScholarCrossref
155.
Kypri  K, Langley  JD, Saunders  JB, Cashell-Smith  ML.  Assessment may conceal therapeutic benefit: findings from a randomized controlled trial for hazardous drinking.  Addiction. 2007;102(1):62-70. doi:10.1111/j.1360-0443.2006.01632.xPubMedGoogle ScholarCrossref
156.
Lin  JC, Karno  MP, Tang  L,  et al.  Do health educator telephone calls reduce at-risk drinking among older adults in primary care?  J Gen Intern Med. 2010;25(4):334-339. doi:10.1007/s11606-009-1223-2PubMedGoogle ScholarCrossref
157.
Maisto  SA, Conigliaro  J, McNeil  M, Kraemer  K, Kelley  ME.  The relationship between eligibility criteria for participation in alcohol brief intervention trials and other alcohol and health-related variables.  Am J Addict. 2001;10(3):218-231. doi:10.1080/105504901750532102PubMedGoogle ScholarCrossref
158.
Manwell  LB, Fleming  MF, Mundt  MP, Stauffacher  EA, Barry  KL.  Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial.  Alcohol Clin Exp Res. 2000;24(10):1517-1524. doi:10.1111/j.1530-0277.2000.tb04570.xPubMedGoogle ScholarCrossref
159.
Mundt  MP, French  MT, Roebuck  MC, Manwell  LB, Barry  KL.  Brief physician advice for problem drinking among older adults: an economic analysis of costs and benefits.  J Stud Alcohol. 2005;66(3):389-394. doi:10.15288/jsa.2005.66.389PubMedGoogle ScholarCrossref
160.
Ockene  JK, Reed  GW, Reiff-Hekking  S.  Brief patient-centered clinician-delivered counseling for high-risk drinking: 4-year results.  Ann Behav Med. 2009;37(3):335-342. doi:10.1007/s12160-009-9108-5PubMedGoogle ScholarCrossref
161.
Paz Castro  R, Haug  S, Kowatsch  T, Filler  A, Schaub  MP.  Moderators of outcome in a technology-based intervention to prevent and reduce problem drinking among adolescents.  Addict Behav. 2017;72:64-71. doi:10.1016/j.addbeh.2017.03.013PubMedGoogle ScholarCrossref
162.
Reiff-Hekking  S, Ockene  JK, Hurley  TG, Reed  GW.  Brief physician and nurse practitioner-delivered counseling for high-risk drinking: results at 12-month follow-up.  J Gen Intern Med. 2005;20(1):7-13. doi:10.1111/j.1525-1497.2005.21240.xPubMedGoogle ScholarCrossref
163.
Reinhardt  S, Bischof  G, Grothues  J, John  U, Meyer  C, Rumpf  HJ.  Gender differences in the efficacy of brief interventions with a stepped care approach in general practice patients with alcohol-related disorders.  Alcohol Alcohol. 2008;43(3):334-340. doi:10.1093/alcalc/agn004PubMedGoogle ScholarCrossref
164.
Roberts  LJ, Neal  DJ, Kivlahan  DR, Baer  JS, Marlatt  GA.  Individual drinking changes following a brief intervention among college students: clinical significance in an indicated preventive context.  J Consult Clin Psychol. 2000;68(3):500-505. doi:10.1037/0022-006X.68.3.500PubMedGoogle ScholarCrossref
165.
Rossi  BV, Chang  G, Berry  KF, Hornstein  MD, Missmer  SA.  In vitro fertilization outcomes and alcohol consumption in at-risk drinkers: the effects of a randomized intervention.  Am J Addict. 2013;22(5):481-485. doi:10.1111/j.1521-0391.2013.12019.xPubMedGoogle ScholarCrossref
166.
Voogt  CV, Poelen  EA, Kleinjan  M, Lemmers  LA, Engels  RC.  The effectiveness of the “What Do You Drink” web-based brief alcohol intervention in reducing heavy drinking among students: a two-arm parallel group randomized controlled trial.  Alcohol Alcohol. 2013;48(3):312-321. doi:10.1093/alcalc/ags133PubMedGoogle ScholarCrossref
167.
Voogt  CV, Poelen  EA, Kleinjan  M, Lemmers  LA, Engels  RC.  Targeting young drinkers online: the effectiveness of a web-based brief alcohol intervention in reducing heavy drinking among college students: study protocol of a two-arm parallel group randomized controlled trial.  BMC Public Health. 2011;11:231. doi:10.1186/1471-2458-11-231PubMedGoogle ScholarCrossref
168.
Wilton  G, Moberg  DP, Fleming  MF.  The effect of brief alcohol intervention on postpartum depression.  MCN Am J Matern Child Nurs. 2009;34(5):297-302. doi:10.1097/01.NMC.0000360422.06486.c4PubMedGoogle ScholarCrossref
169.
Young  CM, Neighbors  C, DiBello  AM, Sharp  C, Zvolensky  MJ, Lewis  MA.  Coping motives moderate efficacy of personalized normative feedback among heavy drinking U.S. college students.  J Stud Alcohol Drugs. 2016;77(3):495-499. doi:10.15288/jsad.2016.77.495PubMedGoogle ScholarCrossref
170.
Cohen  J.  A power primer.  Psychol Bull. 1992;112(1):155-159. doi:10.1037/0033-2909.112.1.155PubMedGoogle ScholarCrossref
171.
U.S. Department of Veterans Affairs. QUERI—Quality Enhancement Research Initiative: AUDIT-C frequently asked questions. QUERI website. https://www.queri.research.va.gov/tools/alcohol-misuse/alcohol-faqs.cfm. 2014. Accessed September 26, 2017.
172.
Williams  EC, Rubinsky  AD, Chavez  LJ,  et al.  An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration.  Addiction. 2014;109(9):1472-1481. doi:10.1111/add.12600PubMedGoogle ScholarCrossref
173.
Jonas  DE, Miller  T, Ratner  S,  et al.  Implementation and quality improvement of a screening and counseling program for unhealthy alcohol use in an academic general internal medicine practice.  J Healthc Qual. 2017;39(1):15-27. doi:10.1097/JHQ.0000000000000069PubMedGoogle ScholarCrossref
174.
Higgins-Biddle  JC, Babor  TF.  A review of the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and USAUDIT for screening in the United States: past issues and future directions.  Am J Drug Alcohol Abuse. 2018;1-9. doi:10.1080/00952990.2018.1456545PubMedGoogle Scholar
175.
Madson  MB, Schutts  JW, Jordan  HR,  et al.  Identifying at-risk college student drinkers with the AUDIT-US: a receiver operating characteristic curve analysis  [published online August 1, 2018].  Assessment. doi:10.1177/1073191118792091PubMedGoogle Scholar
176.
Jonas  DE, Garbutt  JC, Amick  HR,  et al.  Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force.  Ann Intern Med. 2012;157(9):645-654. doi:10.7326/0003-4819-157-9-201211060-00544PubMedGoogle ScholarCrossref
177.
Jonas  DE, Amick  HR, Feltner  C,  et al.  Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis.  JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628PubMedGoogle ScholarCrossref
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