• Colin Drummond, Simon Coulton, Darren James, Christine Godfrey, Steve Parrott, John Baxter, David Ford, Bruce Lervy, Stephen Rollnick, Ian Russell, and Timothy Peters.
• National Addiction Centre, PO48, Institute of Psychiatry, King's College London, 4 Windsor Walk, London SE5 8BB, UK. Colin.drummond@iop.kcl.ac.uk
• Br J Psychiatry. 2009 Nov 1;195(5):448-56.

BackgroundScreening for alcohol use disorders identifies a wide range of needs, varying from hazardous and harmful drinking to alcohol dependence. Stepped care offers a potentially resource-efficient way of meeting these needs, but requires evaluation in a randomised controlled trial.AimsTo evaluate the feasibility, effectiveness and cost-effectiveness of opportunistic screening and a stepped care intervention in primary care.MethodA total of 1794 male primary care attendees at six practices in South Wales were screened using the Alcohol Use Disorders Identification Test (AUDIT). Of these, 112 participants who scored 8 or more on the AUDIT and who consented to enter the study were randomised to receive either 5 minutes of minimal intervention delivered by a practice nurse (control group) or stepped care intervention consisting of three successive steps (intervention group): a single session of behaviour change counselling delivered by a practice nurse; four 50-minute sessions of motivational enhancement therapy delivered by a trained alcohol counsellor; and referral to a community alcohol treatment agency.ResultsBoth groups reduced alcohol consumption 6 months after randomisation with a greater, although not significant, improvement for the stepped care intervention. Motivation to change was greater following the stepped care intervention. The stepped care intervention resulted in greater cost savings compared with the minimal intervention.ConclusionsStepped care was feasible to implement in the primary care setting and resulted in greater cost savings compared with minimal intervention.

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