WHO recommends brief psychological interventions for persons with hazardous and harmful alcohol use. Hazardous drinking is defined as regularly drinking more than the Chief Medical Officers’ guidance of 14 units per week for both men and women, while harmful alcohol use is a pattern of drinking that causes actual damage to health, either physical or mental.
A brief intervention is a short, evidence-based, structured conversation about alcohol consumption. It seeks to motivate and support the individual to consider a change in their drinking behaviour in order to reduce their risk of harm. There are a number of tools designed to help practitioners determine a patient’s level of risk to alcohol harm.
One widely used alcohol screening tool used in primary care is the three-question AUDIT-C assessment which consists of the consumption questions from the full AUDIT (a comprehensive 10 question screening tool). A score of 5 or more indicates the need for additional questions from the full AUDIT tool to be asked. Most GP clinical systems used in the UK have built in either AUDIT-C or another respected screening tool, such as FAST, making it easy to screen your patients.
Several research studies show that brief interventions are effective, particularly in primary care1. They can reduce alcohol consumption among people who are drinking at hazardous or harmful levels, but who are not dependent on alcohol.
For people who are alcohol dependent, referral to specialist alcohol services is the only intervention which is proven to help.
Despite strong evidence and opportunities for brief interventions, they seldom occur. When time is scarce, screening and delivery can be split across two consultations and other practice staff can be trained to take these on. There is free online, self-directed training for brief interventions available for GPs and practice staff; links to these resources are available below.
Evidence suggests brief interventions increase a person's willingness to change and that 1 in 8 actually change their drinking pattern following a brief intervention2.
Furthermore, people are not offended by health professionals asking about their drinking habits, with research showing that patients find it appropriate when GPs take a non-judgmental interest in the wider aspects of their health.
Brief interventions take a supportive, non-confrontational approach, which empowers the patient to recognise the risks associated with their drinking patterns, the benefits of reducing intake, and motivates them to adjust their lifestyle. By including alcohol consumption in routine assessment and management in a range of consultations, including chronic disease management, it can become a natural part of the consultation. When time is an issue, it is worth reinforcing your message by handing the patient written advice to take-away and read before returning for their next appointment.
Opening questions you could use
You might find it helpful to have an armoury of opening questions and comments to help you to raise the subject with your patients. Motivational interviewing principles have been shown to be effective, but they are counterintuitive to much traditional medical training.
Some of the principles include:
- Respect the patient’s ability & responsibility for determining what’s best for themselves,
- Don’t try to persuade, cajole, scare - that is likely to have negative impact
- Ambivalence is to be expected, and is at the core of patient resistance to change
- It’s THEIR job to articulate their ambivalence
- It’s yours to elicit, clarify, and resolve that ambivalence.
Here are some ideas for questions to include3:
“Do you mind if we spend a few minutes talking about…?”
“A lot of people are concerned about changing their drinking patterns…”
Identifying patient’s level of motivation:
“Are you interested in learning more about…?” “What do you know about the benefits of sticking to moderate levels of drinking?”
Exploring patient health beliefs:
“What do you know about the (CMO guidelines/impact of alcohol on your health etc)?” or “What do you know about how your alcohol intake affects your health (or a specific health concern the patient has)?”
Follow up with advice on health risks, if possible tailored to patient’s responses.
Once the patient has identified a health impact, gauge the patient’s priorities:
“On a scale of 1 – 10, with 10 being the most important, how important is it for you to reduce your alcohol levels?” “How do you feel your life or health would improve if you moderated your drinking?”
“What barriers do you think there might be to you achieving this?”
“What practical ways can you think of to overcome any barriers?” (you might prompt the patient here if, for instance, they have identified social events or their social life as a barrier by asking whether enlisting help of friends or family, or adjusting their social schedule to remove the habit of drinking every night, might help).
Open ended questions:
“What do you feel would happen if you do not change your drinking patterns?”
With practice, delivering interventions will become easier for you and your colleagues
Some practitioners may feel that it is futile to discuss alcohol with their patients, believing that many people don’t want to change their drinking patterns. It is important to remember that people’s motivation to change is not fixed – the techniques employed in brief interventions are designed to increase a person’s willingness to change.
As you and your colleagues become more comfortable and confident, broaching the subject and having structured conversations about alcohol harm becomes easier.
- General overview
- Brief alcohol intervention tools overview
- PHE: Alcohol use screening tests
- PHE: Guidance on alcohol use screening tests
- E-Learning for Health includes brief alcohol intervention module developed jointly with PHE [free to NHS staff including GPs]
- Royal College of Psychiatrists: Substance misuse factsheets – assessment and screening tools
- Health Scotland: Alcohol Brief Interventions resources