Compared with controls, problem drinkers who receive a brief intervention are twice as likely to moderate their drinking at 6 to 12 months25 and significantly reduce alcohol intake by approximately 4 drinks per week at follow-ups of 12 months or more.8,10,26 In addition, providing brief interventions significantly decreases the proportion of individuals whose alcohol intake exceeds recommended levels.10 A meta-analysis and a systemic review indicate brief interventions for problem drinkers reduce morbidity and mortality resulting from motor vehicle crashes, falls, suicide attempts, domestic violence, assaults, and child abuse.5,27
A brief intervention
Screening and brief intervention guidelines suggest a standard approach for assessing and managing problem drinking and alcohol use disorders.7,16 This approach can be described by the “5 As of intervention” (Table 1),10 which is one way to summarize the different brief intervention strategies described in the literature.7,9,10,16-18,28-30
Ask. Asking a question about any alcohol use is a simple way to initiate a conversation about the topic (“Do you sometimes drink beer, wine, or other alcoholic beverages?”). Incorporating questions about alcohol consumption into inquiries about other health habits (eg, smoking, exercise) may decrease patients’ defensiveness. If your patient reports using alcohol, follow up by screening for ≥5 drinks a day for men or ≥4 drinks a day for women (“In the past year, how many times have you had 5 or more drinks a day?”). Use at this level ≥1 times a year indicates a positive screen that provides good sensitivity and specificity for detecting problem drinking and alcohol use disorders.18 Then ask about weekly alcohol intake (“On average, how many days a week do you have an alcoholic drink?” “On a typical drinking day how many drinks do you have?”). Presenting a chart that describes what constitutes a standard drink—available from the NIAAA (see Related Resources)—may be helpful.
You also can use additional questions from the CAGE screening test (Table 2).31 In clinics with a more formal screening protocol, patients may be asked to complete a written self-report such as the Alcohol Use Disorders Identification Test (AUDIT). This 10-question survey covers domains of alcohol consumption, drinking behavior, and alcohol-related problems.17,18 If your patient is a problem drinker, further assessment could determine if he or she has an alcohol use disorder.
Advise. Provide feedback about your patient’s drinking and its consequences along with clear recommendations in an empathic, nonconfrontational manner (“You’re drinking more than is medically safe; I strongly recommend you cut down”). Comparing your patient’s drinking pattern to population norms may be helpful (“Less than 20% of people drink a much as you”).7,16 When possible, tie the consequences of the patient’s drinking to his or her current physical, mental, family, social, and legal concerns. Convey your concerns empathically, as a medical provider providing health recommendations (“As your doctor, I am concerned about how much you drink and how it is affecting your health”). However, to respect patient autonomy, give a medical recommendation, rather than a directive (“As your doctor, I feel I should tell you” rather than “You should”). Finally, express a clear message of your willingness to help.
Assess your patient’s readiness to change (“Given what we’ve talked about, are you willing to consider making changes in your drinking?”). Showing the links between alcohol use and personal consequences may improve patient engagement (“If you keep drinking at your current levels, do you think your goal of improving your grades will be easier, harder, or no different?”).28 If your patient is willing to make a change, negotiate a patient-specific goal, such as reducing drinking to within the recommended limits, using alcohol only a few days a week instead of every day, or abstaining for a defined period. If the patient is not willing to change, restate your concern regarding his or her health-related consequences and your willingness to help.
Assist. After you’ve negotiated a goal with your patient, discuss a treatment plan to help the patient achieve the goal. This should include steps the patient will take to reduce or quit drinking. Consider offering handouts on standard drink sizes, alcohol-associated harms, and strategies for cutting down or abstaining (eg, pacing use, spacing drinks by including nonalcoholic beverages, plans to handle urges, using alcohol money for other items), and calendars for tracking drinking (ie, a drinking diary). Help your patient identify situations where he or she is likely to have difficulty achieving the goal and strategies for avoiding or managing such situations. Ask patients to identify a family member or friend who can help them. Refer patients who have an alcohol use disorder to addiction treatment.