E-Interventions for Alcohol Misuse
The economic, social, and health burden of alcohol misuse is widely recognized, as is the need for effective interventions to reduce this burden. Alcohol misuse constitutes the third leading cause of morbidity and mortality worldwide and is the third leading cause of preventable death in the United States, after tobacco use and obesity. Substance use disorders, including alcohol use disorder (AUD), are among the most common and costly conditions in Veterans seeking Veterans Health Administration (VHA) treatment. Among Veterans with at least one VHA primary care visit within the past year, nearly 600,000 screened positive for alcohol misuse, and almost 400,000 had a diagnosis of AUD.
Given the size and severity of the problem, the use of Internet or other technology-based interventions could be an important addition to treatment options within VHA. Electronic interventions (e-interventions) have the potential to reach those individuals with drinking problems who wish to remain anonymous; those who live at great distance from, cannot afford, or have little time for traditional therapy; and shift workers who need treatment to be available during non-standard business hours. Given that Veterans can encounter most, if not all, of these barriers to accessing care for alcohol misuse, e-interventions may prove a promising new avenue, especially for the younger, more Internet-savvy Veterans returning from Iraq and Afghanistan.
However, a systematic review conducted by the VA Evidence-based Synthesis Program Center at the Durham Veterans Affairs Healthcare System found that limited evidence from recent studies suggests that electronic interventions have little to no effect on long-term (≥ 6 months) alcohol misuse. And yet, the authors note that the available trials typically included only online or computer-based e-interventions of one session lasting 30 minutes or less, and that further research is needed to determine whether higher intensity interventions would have longer term effects.
Although previous studies have shown that low-intensity, in-person interventions have led to decreased drinking among those who misuse alcohol, similar e-interventions didn't show the same results, and current evidence would not support substitution of e-interventions for brief, in-person treatment. However, a sensitivity analysis limited to studies at low or moderate risk of bias found a small, statistically significant reduction among alcohol misusers. This finding supports the need for future research to determine with higher confidence whether e-interventions can produce long-term benefits for alcohol-related outcomes. In particular, given the limited number and duration of intervention episodes in the studies reviewed, it is possible that these e-interventions were not designed to be robust enough to produce significant, enduring effects on alcohol misuse.
Other questions to consider include whether e-interventions would be effective in patients who are older, have less education, or more comorbidities; whether more portable platforms such as iPods and smartphones would improve compliance; and whether e-interventions could be effective in patients with AUD. All of these questions could be answered by properly designed controlled trials. Questions about the validity of self-reported outcomes could also be addressed by studies that use bioverification measures or mobile monitoring.
Although the current state of the evidence does not support long-term benefit from e-interventions for alcohol misuse, the evidence for short-term effects from low-intensity interventions and longer-term effects from a higher intensity intervention using a smartphone application that is integrated with clinical counseling suggests the potential for benefit, particularly as technologies change, becoming more prevalent and more engaging.
"Electronic platforms are constantly evolving and becoming more convenient, easier to use and more engaging. Because of this potential, the prevalence of alcohol use disorders, and their high cost to the health and welfare of Veterans, it is worth pursuing additional research into longer-term, more personalized and engaging e-interventions," suggests Karen Drexler, M.D., Deputy National Program Director for Addictive Disorders in Mental Health Services.
Dedert E, Williams JW Jr., Stein R, McNeil JM, McDuffie J, Ross I, Feiermuth C, Hemminger A, Kosinski A, Nagi A. Evidence Report: E-Interventions for Alcohol Misuse. VA ESP Project #09-009; 2014.
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