Evidence-Based Reviews

Strategies to reduce alcohol use in problem drinkers

Current Psychiatry. 2011 November;10(11):30-42

References

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For patients who are not willing to change, discuss the perceived benefits of continued drinking vs reducing or stopping drinking to encourage them to reflect on their alcohol use patterns. Discuss any potential barriers to change. Keep in mind ambivalence and reluctance to change drinking patterns are common and many patients are unaware of the risks of their alcohol use. This discussion may lead patients to contemplate change later.

Arrange. Schedule a follow-up appointment to reinforce the treatment plan with further support, feedback, and assistance in setting, achieving, and maintaining realistic goals. Consider a follow-up phone call 2 weeks after the brief intervention to check on progress and a follow-up appointment in 1 month. Clinical staff may have the opportunity to e-mail or text message patients to check on progress between face-to-face visits. At the follow-up appointment, ask if your patient was able to meet and sustain the drinking goal. If so, support continued adherence, renegotiate drinking goals if indicated, and encourage follow-up with at least annual rescreening. When patients are unable to meet their treatment goals, acknowledge that change is difficult, encourage any positive changes, and address barriers to reaching the goal. Reemphasize your willingness to help, reevaluate the diagnosis, treatment plan, and goals, and schedule close follow-up. Consider engaging significant others in the treatment process.

Table 1

Brief interventions: ‘5As’ to address alcohol use

Ask: Screen for use ‘Do you sometimes drink beer, wine, or alcohol?’ ‘In the past year, how many times have you had 5 or more drinks in a day?’
Advise: Provide strong direct personal advice to change Empathic, nonconfrontational feedback on drinking pattern and consequences Relate consequences to current health, family, social, and legal issues State concern and recommend change
Assess: Determine willingness to change Discuss what the patient likes and dislikes about drinking Discuss life goals Determine how willing the patient is to change and what he or she is willing to change Agree on a mutually acceptable goal
Assist: Help the patient make a change if he or she is ready Set mutually agreed upon specific goals (how many days, how many drinks) Encourage a written risk reduction agreement (‘Rx’) Provide techniques (diary cards, pace, space, switch, include food) Identify high-risk situations Identify supporters (family, friends) Self-help manual
Arrange: Reinforce change effort with follow-up Make a follow-up appointment Provide supportive telephone consultations Refer patients to a specialty treatment if necessary
Source: Reference 10

Table 2

CAGE questionnaire to detect alcohol use disorders

Cut down	‘Have you ever felt you ought to cut down on your drinking?’
Annoyed	‘Have people annoyed you by criticizing your drinking?’
Guilt	‘Have you ever felt bad or guilty about your drinking?’
Eye-opener	‘Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?’
Source: Reference 31

Use in psychiatric practice

Clinical Point

When patients do not meet their treatment goals, acknowledge that change is difficult, encourage positive changes, and address barriers

Problem drinking may not be adequately addressed in psychiatric settings. In a survey of problem drinkers identified in the general population, only 64% discussed their drinking during a mental health visit and only 40% received counseling about their alcohol use from their mental health provider.³² In a study of 200 psychiatric inpatients, 49% exhibited problem drinking as measured by AUDIT, but only 27% of patients had alcohol use recorded in their medical record.³³ In addition, routine use of screening tools such as CAGE or AUDIT appears to be low in many psychiatric settings even though research has shown that tools such as AUDIT or computerized screening may be effective for identifying problem drinking in psychiatric outpatient settings.^20,21,34

Several small studies support the efficacy of brief interventions for problem drinking in psychiatric settings. A study in a psychiatric emergency service found patients with either schizophrenia/bipolar disorder or depression/anxiety decreased their drinking by about 7 drinks a week over 6 months after a brief intervention.¹⁵ This study was small and the decrease in alcohol intake was not significant within the 2 population groups (P = .10 for schizophrenia/bipolar disorder, n = 34, P = .05 for depression/anxiety, n = 53); however, there was a significant decrease for all patients with follow-up (P = .0096, N = 55).¹⁵ In another study, psychiatric inpatients with problem drinking who received a brief motivational intervention demonstrated a statistically significant reduction in alcohol consumption at 6 months compared with patients who received only an information packet,¹³ but health-related outcomes at 5 years did not differ between the 2 groups.¹⁴ Finally, in a study of 344 nonpsychotic psychiatric outpatients with problem drinking, one-half of those who received a brief telephone intervention reduced their drinking to non-hazardous levels at a 6-month follow-up (intervention 43.8%, control 27.7%).¹²