Journal Article

Implementing primary healthcare-based measurement, advice and treatment for heavy drinking and comorbid depression at the municipal level in three Latin American countries: final protocol for a quasiexperimental study (SCALA study)

O'Donnell, Amy, Anderson, Peter, Natera Rey, Guillermina, Matrai, Silvia, Rowlands, Gillian, Schulte, Bernd, V Bustamante, Ines, Braddick, Fleur, Rehm, Jürgen, Pérez Gómez, Augusto, Solovei, Adriana, Mercken, Liesbeth, Kaner, Eileen FS, de Vries, Hein, Kokole, Daša, Manthey, Jakob, Schmidt, Christiane, López-Pelayo, Hugo, Mejía Trujillo, Juliana, Gual, Antoni, Jané-Llopis, Eva, Pérez De León, Alexandra, Piazza, Marina

2020

Overview

Heavy drinking is a cause of considerable disability, morbidity and mortality.2 Heavy drinking is a causal factor for some communicable diseases (including TB and HIV/AIDS), for many non-communicable diseases (NCDs, including cancers, cardiovascular diseases and gastrointestinal diseases) and for many mental and behavioural disorders, including depression, dementias and suicide.3 4 In PHC settings, two-fifths of people with heavy drinking have depression, with risks of incident depression higher for heavier as opposed to lighter drinkers.5 In addition to its role in the aetiology of depression, heavy drinking is associated with worsening the depression course, including suicide risk, impaired social functioning and impaired healthcare utilisation.6 Heavy drinking is also a major contributor to global health inequalities, with alcohol-related harm aggravated by lower socioeconomic status7 and extending beyond the individual drinker to families, communities, health systems and the wider economy. Tackling the multiple individual and societal level harms caused by heavy drinking is essential for achieving global targets of reducing deaths from NCDs by 25% between 2010 and 2025,8 more so as risk of exposure to harmful use of alcohol increases with increasing socioeconomic status.9 In line with tackling harm due to lower socioeconomic status, United Nations Sustainable Development Goals include Target 3.5, to strengthen the prevention and treatment of harmful use of alcohol, with two proposed indicators: coverage of treatment interventions (pharmacological, psychosocial and rehabilitation and aftercare services) for harmful use of alcohol; and per capita alcohol consumption.10 11 Countries in Latin America have the highest alcohol-attributable disease burden after Eastern Europe and sub-Saharan Africa, with particularly high risks in alcohol-attributable traffic injury including violence.12 The burden of alcohol-attributable diseases in Latin America lead to marked economic costs, with numerous calls to implement effective and cost-effective policies.13 A robust and extensive body of literature demonstrates the range of evidence-based strategies that can be implemented to reduce heavy drinking in healthcare settings.14 Questionnaire-based measurement and brief advice programmes delivered in PHC are effective15 and cost-effective16 17 in reducing heavy drinking. In addition to brief advice, treatment for heavy drinking includes cognitive behavioural therapy and pharmacotherapy, both of which are found to be effective in reducing heavy drinking.18 Were the proportion of eligible patients receiving advice and treatment for heavy drinking to increase to 30% of eligible patients, the prevalence of harmful use of alcohol could decrease by between 10% and 15% across OECD (Organisation for Economic Co-operation) and member countries.19 However, to date, measurement and brief advice and treatment programmes have failed to achieve widespread take-up.19 Two systematic reviews20 21 and two multicountry studies22–24 have demonstrated that the proportion of PHC patients whose alcohol consumption is measured, and of heavy drinking patients given advice can be increased by providing training and support to PHC providers, although from very low baseline levels, and with effects not generally sustained over the longer term. [...]while there has been some previous research in countries of Latin America,25–30 most implementation work to date has been undertaken in high-income countries. Similar conclusions were reached by the European Optimising Delivery of Healthcare Interventions (ODHIN) study42 and the US-based Substance Abuse and Mental Health Services Administration Screening, Brief Intervention and Referral to Treatment initiative.43–45 The second barrier is that standard cut-off points for the frequently used alcohol measurement instrument, Alcohol Use Disorders Identification Test, 3-item consumption version (AUDIT-C)46 (commonly a score of five for both men and women, or five for men and four for women) to trigger advice are too low,47 being equivalent to an average daily alcohol consumption of about 20 g of alcohol (around two standard drinks) or less.48 Practitioners may well find it problematic to give advice at such levels, which would also have huge time implications, with one in three or four patients being eligible for advice in many countries, under this criterion.24 49 We have argued to adopt similar models to blood pressure, where cut-off points for managing raised blood pressure are often determined by levels of blood pressure at which treatment has shown to be effective.50 51 Similarly, cut-off points for brief advice could be the baseline levels of alcohol consumption found in the randomised controlled trials that have investigated the effectiveness of PHC-delivered brief advice.

• Publisher: British Medical Journal Publishing Group,BMJ Publishing Group LTD,BMJ Publishing Group
• Subject: Alcohol use / Alcoholism - diagnosis / Alcoholism - epidemiology / Alcoholism - therapy / Blood pressure / Cities / Cognitive behavioral therapy / Comorbidity / Costs / depression & mood disorders / Depression - epidemiology / General practice / Family practice / Humans / Hypotheses / Intervention / Latin America / Mental depression / primary care / Primary Health Care - methods / Program Development / Socioeconomic factors / substance misuse