Three main points:

• The failures of brief interventions for alcohol abusers result of failures of the previous screening supposed to be required.
• Four tools are suggested in order to multiply brief intervention without screening.
• Four scenarios are prepared: for the Internet surfer, the physucian, the nurse and the student.

TOOLS

Four tools are available on this website. Several scenarios for using them will be suggested

1, Screening: health questionnaire for daily medical practice, available for general practitioners, workplace physicians, nurses and medical students, as well as for the general public. It includes no questions on alcohol consumption, but 11 questions easily lead to a talk about alcohol: sleep, tranquilizers, tiredness, anxiety, poor memory, depression, suicidal ideas, hypertension, cramps, gout, tremor and after-effects of accidents.
Concerning alcohol, it is more a case-finding than a screening questionnaire.
2, Drugs, suicide, alcohol : my freedom, my health. Leaflet for the waiting-room  It deals with drugs and suicide as well as with alcoholism so that hose picking up the leaflets do not feel stigmatized for their alcohol problems. The leaflet stresses freedom, security and the motives declared in a sample survey for being moderate or for abstaining.
3, Smoking, drinking: where am I at? starts with smoking. Concerning alcohol, it focuses on suffering and on degrees of dependence rather than on consumption. The choice between moderation and abstinence is explained, as well as the self-assessment of the outcome.
4, A book Drugs, alcohol: talking within the family is written for the relatives of alcohol victims.
Other pages of the website deal with prevention and mental health education. The last one provides Alcohol and -smoking addict : outline of a case report 

SEVERAL SCENARIOS FOR USING THE TOOLS

The scenario is different for an Internet user, a general practitioner, a medical or nursing student, a workplace physician or nurse.

Internet users are attracted if they are interested in healthy sport, smoking, drugs, or suicide as well as alcohol.
They then find the self-assessment questionnaire:
Smoking, drinking : where am I at?  which mentions the leaflet. Both may be regarded as brief interventions including self-screening.
They also find the
Screening: health questionnaire for daily medical practice:
an additional motive for consulting.

Heavy drinkers are also concerned by the pages devoted to suicide- and drug prevention.
If the Internet user has no personal problems with alcohol
but has a heavily drinking relative, he may be interested in reading
the book:Drugs, alcohol: talking within the family

A general practitioner may amend and print
Drugs, suicide, alcohol : my freedom, my health. Leaflet for the waiting-room 
to be left in the waiting-room and
the health questionnaire
Screening: health questionnaire for daily medical practice
to be given when entering the waiting-room and to be read before the physical examination.
The answers are enough to start questioning about being alcohol problems, during or after the physical examination. For instance, Have you ever felt we might consider together the place of alcohol in your life?

The GP, the nurse (Babor 2004) or the chemist, who often smells the problem (Pouyet-Poulet 2001), may otherwise give up screening but print the self-assessment questionnaire
Smoking, drinking : where am I at?  about smoking and alcohol, give it to all smokers for their being smokers and ask them to come another day for a further talk, if they like.
To the relatives of addicts, the GP or nurse may suggest
the book  Drugs, alcohol: talking within the family

The midwife may whisper to pregnant women that they might not be overjoyed at baby's being badly disabled in a car which would have been driven under influence; or that they might not be overjoyed at baby's father being dismissed for his alcoholism; or at their child's growing in a family alcohol or drugs have made havoc of. She may disclose the
Smoking, drinking : where am I at? for the father of the fetus.

Medical and nursing students may be interested to learn from the book
Drugs, alcohol: talking within the family how to interview alcohol dependents or abusers. They may amend and print the tools. Using them already works as a brief intervention.

The workplace physician or nurse may print the same tools. A special page
Alcoholism in workplace medicine  in the website tells more.

DISCUSSION

The literature about screening before brief intervention, the previously printed self-assessment tools, the tools available on the Internet and the evaluation of the outcome will be discussed in turn.

Brief interventions, if delivered with empathy, proved effective, with better results in male non-dependent heavy drinkers (Edwards 1977, W. Miller 1981, Ockene 1999, Kaner 2007). The benefit-cost ratio was excellent (French 2004).
These brief interventions required screening people having alcohol problems before hand. Questionnaires were the most commonly used screening tools. The first question of the CAGE may be enough (Escobar 1995). The successes of the Gps using the questionnaires CAGE, MAST, AUDIT, AUDADIS and M-CIDI have been reviewed (Yersin 1999).

Unfortunately, most general practitioners gave up screening once their research period was over (personal communication at ISBRA 1998 from Drs Saunders, Allen, Kristenson, Andreasson, Fauske, Sillanaukee).
A few publications say so (Macqueen 1997, Andreasson 1998, Spandorfer 1999, Beich 2002, Aalto 2003). Half of the GPs trained to screening gave up cooperating to a research on brief intervention (Huas 2002).
It was damageable, as the results showed that screening alone worked as well as brief intervention.

Three explanations might be suggested:
1, The purpose of brief interventions, supported by W.H.O., is that people drink less. The outcome was evaluated by counting the drinks. Were this purpose and this accountancy motivating enough for the Gp and his patient ?
2, Was it appropriate to ask questions about alcohol intake before the physical examination?
3, Was it necessary that brief intervention depend on a previous screening, if screening is a failure?
4, GPs argue lack of time, training, belief and incentives (Heather 2004).

Other ways of screening were explored. Blood markers are well known. GPs take better advantage of markers to confirm intoxication and evaluate the treatment than to screen (Meerkerk 1999). Indirect ways to bring the topic of alcohol are raising questions about traumas (Israel 1996), clinical case finding (Cornel 1996). Finally, screening is far from optimal, so the great majority of heavy drinkers do not benefit from brief interventions.

Printed self-assessment tools are available. The leaflet of the Comité Français d’Éducation pour la Santé and some English ones (Heather 1987, Finfgeld 2000) focuses on alcohol consumption.

Over 12,500 websites deal with alcohol, most of them promoting alcoholic beverages.
Many sites are directories, or issued by selfhelp groups, or deliver scientific matters, or advertise therapies.
For the general public, some sites provide information on risks (Vella 1998 and references starting by www) like the published witnesses of recovered addicts (Jack London 1913, Lucien 1990). W.R.Miller's dozens of self-assessment Pages focus as well on the daily life of drinkers as on their consumption, but only a professional intervener can make it out.
We did not find Pages similar to our health questionnaire, handout, self-assessment, and case report.

The tools presented here avoid confrontational questions on alcohol consumption. The health questionnaire and handout were quite well accepted in GPs’s waiting rooms. The tools have not yet been tested with nursing students.

Preparing for smokers the self-assessment
Smoking, drinking: where am I at? 
needs 4 minutes for copyng-pasting, then the time for printing and photocopying the four pages.
Afterwards, it doesn't cost any time.
It is the briefest of brief interventions.

If it is read, is it as efficient as the screening performed by the GP without ensuing brief intervention (Huas, Pessione, Bouix, Demeaux, Allemand, Rueff 2002)
For evaluation, see below.

The advantages of the Internet for brief intervention with or without professional screening are theoretically numerous.
It aims at an universal prevention, calling all members of a society to evoluate (Craplet 1998).
The reach is quantifiable.
The texts may be amended by their author as well as by the users.
The users may be repeatidly contacted through Email (Collins, Brown).
The cost is low, except in terms of time taken by the author, so that no advertising is needed.

The weak points of the Internet are the “cacophony” and the task of finding the relevant sites among three billions.
The messages are not medical advice, they are not targeted at particular cases.
Health is one of the most popular topics on the web, but perhaps not for young people.
As the Internet does not allow for control groups to be created, its efficacy among Internet users cannot be evaluated.

When evaluating the outcome in more motivating terms than counting the drinks, physicians and nurses may randomize their patients whether or not they use the printed tools: for instance, using the tools one month or one year out of two.

Possible criteria:
• the number of discussions about alcohol following the health questionnaire or the self assessment about tobacco and alcohol;
• the number of brief interventions following perplexing requests for sleeping, anxiolytic or fortifying tablets;
• recording, in the absence of comorbity: the accidents, the hospital days, the quality of life and of the human relationships.

Conclusion

The four tools spare the time of screening
and the time of intervention.

They provide a self-screening
which is a first brief intervention

REFERENCES

Presented as poster at the eighth congress of ESBRA (European Society for Biomedical Research on Alcoholism) Paris 2001. Published as Summary :
Besançon F: Using the Internet for self-assessment of tobacco-alcohol dependence and for brief interventions without screening. Alcohol & Alcoholism 2001; 36 (5): 50

- Aalto M, Pekuri P, Seppä K: Obstacles to carrying out brief intervention for heavy drinkers in primary health care: a focus group study. Drug & Alcohol Rev 2003; 22 (2): 169-173
- Andreasson S: Why isn’t everyone doing brief intervention? Alcoholism Clin Exp Res 1998; 22 (Suppl 3): 155A
- Babor TF. Introduction de l'intervention brève dans les systèmes de santé. L'étude Cutting Back aux États-Unis. Alcoologie & Addictologie 2004; 26 (3 Suppl): 30 S-33 S
- Beich A, Gannik D, Malterud K: Screening and brief intervention for excessive alcohol use:  qualitative interview study of the experiences of general practicioners. Brit Med J 2002; 325   (7369): 870-874
- Bertholet N, Schwan R, Duhamel O, Perney P, Daeppen JB : Efficacité de l'intervention  brève. Alcoologie & Addictologie 2003; 25 (4S): 59S-63S
- Brown RL, Saunders LA, Bobula JA, Mundt MP, Koch PE. Randomized-controlled trial of a telephone and mail intervention for alcohol use disorders: three-month drinking outcomes. Alcohol Clin Exp Res. 2007;31(8):1372-1379
- Collins GB, McAllister MS, Ford DB. Patient-provider e-mail communication as an adjunctive tool in addiction medicine. J Addict Dis. 2007;26(2):45-52
- Comité Français d’Éducation pour la Santé: Et vous avec l’alcool, vous en êtes où? Paris, CFES, no date
- Cornel M, Knibbe RA, Knottnerus JA, Volovics A, Drop M: Predictors for hidden problem  drinkers in general practice. Alcohol & Alcoholism 1996; 3 (3): 287-296
- Craplet M: La prévention du risque alcool: fondements scientifiques et actualité. Alcoologie  1998; 20 (3): 245-252
- Epstein EE, Drapkin ML, Yusko DA, Cook SM, McCrady BS, Jensen NK Is alcohol assessment therapeutic? Pretreatment change in drinking among alcohol-dependent women.. J Stud Alcohol. 2005 May;66(3):369-78.
- Escobar F, Espi F, Canteras M: Diagnostic tests for alcoholism in primary health care: compared efficacy of different instruments. Drug & Alcohol Dep 1995; 40: 151-158
- Edwards G, Orford J, Egert S, Guthrie S, Hawker A, Hensman C, Mitcheson M, Oppenheimer E, Taylor C: Alcoholism: a controlled trial of "treatment" and "advice". J Stud   Alc 1977; 38: 1004-1031
- Ferguson L, Ries R, Russo J. Barriers to identification and treatment of hazardous drinkers as assessed by urban/rural primary care doctors. J Addict Dis. 2003; 22(2): 79-90
- Finfgeld DL: Use of self-help manuals to treat problem drinkers. J Psychosoc Nursing &  Mental Health Services 2000; 38 (4): 20-27
- French M. Efficacité des interventions brèves en alcoologie. Alcoologie & Addictologie 2004; 26 (3 Suppl): 20 S-23 S
- Heather N. Repérage et prise en charge des problèmes d'alcool en médecine de premier recours. Le projet de l'OMS. Alcoologie & Addictologie 2004; 26 (3 Suppl): 34 S-40 S
- 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   Royal   College General Practic 1987; 37: 358-363
- Huas D, Pessione F, Bouix JC, Demeaux JL, Allemand H, Rueff B: Efficacité à un an d'une intervention brève auprès des consommateurs d'alcool à problèmes. Rev Praticien Méd Gén 2002; 16 (586): 1343-1348
- Israel Y, Hollander O, Sanchez-Craig M, Booker S, Miller V, Gingrich R, Rankin JG:  Screening for problem drinking and counseling by the primary care physician-nurse team. Alcoholism Clin Exp Res 1996; 20 (8): 1443-1450
- Kaner EF, Beyer F, Dickinson HO et al. Effectiveness of brief alcohol interventions in primary care populations Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004148.
- London J: John Barleycorn. New York, Macmillan1913
- Lucien: L’enfant qui jouait avec la lune, 7° édition. Mulhouse, Salvator 1990
- Lukasiewicz M, Benyamina A, Frenoy-Peres M, Reynaud M. L'entretien motivationnel. I- Les bases théoriques. Alcoologie & Addictologie 2006; 28(2): 155-162
- Lukasiewicz M, Benyamina A, Frenoy-Peres M, Reynaud M. L'entretien motivationnel.. II Les aspects techniques. Alcoologie & Addictologie 2006; 28(3) 231-235
- Macqueen AR: Why general practicioners might avoid drug and alcohol work. Drug & Alcohol Review 1997; 16 (4): 429-431
- Meerkerk GJ, Njoo KH, Bongers IM, Trienekens P, van Oers JA: Comparing the diagnostic  accuracy of CDT, GGT and MCV in a general practice population. Alcoholis Clin Exp Res 1999; 23 (6): 1052-1059
- Miller WR, Gribskov CJ, Mortell RL: Effectiveness of a self-control manual for problem drinkers with and withour therapist contact. Internat J of the Addict 1981; 16: 1247-1254
- Miller WR. Enhancing motivation for change in substance abuse treatment. Rockville, MD US Dept health Human Serv, Center Subst Abuse Treatm, 1999
- Miller PM, Thomas SE, Mallin R.ÊPatient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol Alcohol. 2006 May-Jun;41(3):306-10. Epub 2006 Mar 30.
- Miller WR : http://casaa.unm.edu
- Ockene JK, Hurley AA, Wheeler EV, Hebert JR: Brief physician- and nurse practicioner- delivered counseling for high-risk drinkers: does it work? Arch Int Med 1999; 159 (18):   2198-2205
- Perney P, Dépinoy D, Duhamel O: Interventions brèves. Modalités. Alcoologie & Addictologie 2003; 25 (4S): 51S-58S
- Pouyet-Poulet E, Sauvant MP, Pépin D, Planche R: Le pharmacien d'officine face au problème des buveurs excessifs. Santé Publ 2001; 13 (3): 237-248
- Sobell LC, Sobell MB, Leo GI, Agrawal S, Johnson-Young L, Cinningham JA: Promoting self-change with alcohol abusers: a community-level mail inrervention based on natural recovery studies. Alcohol Clin Exp Res 2002; 26 (6): 936-948
- Spandorfer JM, Israel Y, Turner BJ: Primary care physicians views on screening and   management of alcohol abuse: inconsistencies with national guidelines. J Family Practice 1999; 48 (11): 899-902
- Tonnesen H, Rosenberg J, Nielsen HJ et coll. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. Brit Med J 1999;   318: 1311-1316
- Vella D, Hautefeuille M, Lautran-Davoux C, Vazeille G : Les sites Internet concernant l’alcool et la maladie alcoolique. Alcoologie 1998; 20 (2): 161-165
- Yersin B: Les questionnaires de dépistage en alcoologie. Alcoologie 1999; 21 (3): 397-401

Website in English:
- www.ccsa.ca/cclat.htm
Websites in French:
- ANPAA, Association de préventioin en Alcoologie et Addictologie
- www.prevention.ch

Top of this Page

• •  Your questions: type: fbesan and add @gmail.com • •

Copies authorized if mentioning the source:
the url at the top of thid Page