Telephone-based, stepped care strategies have the potential to improve delivery of alcohol interventions in primary care settings. In a controlled trial, researchers randomized 408 primary care patients with at-risk drinking,* heavy drinking,** alcohol abuse, and alcohol dependence to full care (computerized feedback plus four 30-minute telephone interventions), stepped care (computerized feedback plus up to three 40-minute telephone interventions, depending on response), or a control group (no alcohol intervention). Telephone interventions were based on motivational interviewing and delivered by trained psychologists.

• The baseline ranges of unhealthy alcohol use levels among the 3 arms were as follows:
  • at-risk drinking, 21–33%
  • heavy drinking, 24– 30%
  • alcohol abuse, 12–17%
  • alcohol dependence, 26–38%
    
    
• Compared with controls, participants in the intervention groups (full care and stepped care combined) reported a greater decrease in grams of alcohol per day from baseline to 12 months (-12.6 versus -6.3 in the overall sample; -17.9 versus -3.7 in the alcohol abuse/at-risk drinking subgroup) and a lower proportion of binge drinking at 12 months (25% versus 41%) in the alcohol abuse/at-risk drinking subgroup.
  
  
• Outcomes did not differ between the control and intervention groups for subjects with alcohol dependence or heavy drinking.
  
  
• Outcomes were similar in the full care and stepped care groups. The stepped care group received 50% of the counseling time (40 versus 80 minutes) received by the full care group.

Comments by Tommie Ann Bower, MA
Although the value of brief intervention for problem drinking has been established, the time it takes to administer it remains a barrier in clinical settings. This study shows that a pared down approach can have an equal impact, although this may surprise some practitioners. Finding financial coverage for such a simple approach and embedding it as a care option will likely prove less simple.