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National Institute on Alcohol Abuse and Alcoholism No. 43 April* 1999
*This is the first Alcohol Alert of 1999. There will be a total of four issues of Alcohol Alert published within the calendar year.
Brief Intervention for Alcohol Problems
Nearly one-fifth of patients treated in general medical practices report
drinking at levels considered "risky" or "hazardous" (
1,
2) and may be
at risk for developing alcohol-related problems as a result. Brief intervention,
which can be conducted in general health care settings, can help patients reduce
that risk. Brief intervention is generally restricted to four or fewer sessions,
each session lasting from a few minutes to 1 hour, and is designed to be
conducted by health professionals who do not specialize in addictions treatment.
It is most often used with patients who are not alcohol dependent, and its goal
may be moderate drinking1 rather than abstinence (4-6). The content
and approach of brief intervention vary depending on the severity of the
patient's alcohol problem. Although the approaches used in brief intervention
are similar for alcohol-dependent and non-alcohol-dependent patients, the goal
of brief intervention for alcohol-dependent patients is abstinence. Most of the
findings in this Alcohol Alert relate to the use of brief intervention
with non-alcohol-dependent patients treated in general health care settings.
However, brief intervention also has been used to motivate alcohol-dependent
patients to enter specialized treatment with the goal of abstinence (7) and has
been studied as an alternative to long-term treatment in specialized alcohol
treatment settings (8,9). This Alcohol Alert explains the components of
brief intervention and considers the effectiveness of this approach.
Screening for Alcohol Problems
A number of screening tools are available to identify current or potential
alcohol problems among patients (see Alcohol Alert No. 8, "Screening for
Alcoholism" [10]). Medical history questionnaires can pose questions about
current and past alcohol use, including quantity and frequency of drinking (6).
Questions about a patient's previous accidents and injuries can elicit clues to
a potential alcohol problem (11). Several standardized screening questionnaires,
such as the Alcohol Use Disorders Identification Test (AUDIT) (12), the CAGE
(13), and the Michigan Alcoholism Screening Test (MAST) (14) and its derivatives
(e.g., the Brief MAST [15]), can identify alcohol problems among current
drinkers (16).2 Laboratory tests, such as the test for the liver
enzyme gamma-glutamyltransferase (GGT), may also reveal the presence of
unsuspected alcohol problems (6).
Common Elements of Brief Intervention
Research indicates that brief intervention for alcohol problems is more
effective than no intervention (e.g., 1,17-19) and often as effective as more
extensive intervention (e.g., 4,8). To identify the key ingredients of brief
intervention, Miller and Sanchez (20) proposed six elements summarized by the
acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy,
and self-efficacy. The importance of these elements in enhancing effectiveness
has been supported by further review (4). Goal setting, followup, and timing
also have been identified as important to the effectiveness of brief
intervention (5).
Feedback of Personal Risk. Most health professionals delivering
brief intervention provide patients with feedback on their risks for alcohol
problems based on such factors as their current drinking patterns; problem
indicators, such as laboratory test results; and any medical consequences of
their drinking (1,17,21). For example, a physician may tell a patient that his
or her drinking may be contributing to a current medical problem, such as
hypertension, or may increase the risk for certain health problems (22).
Responsibility of the Patient. Perceived personal control has
been recognized to motivate behavior change (23). Therefore, brief intervention
commonly emphasizes the patient's responsibility and choice for reducing
drinking (e.g., 8). For example, a doctor or nurse may tell patients that "No
one can make you change or make you decide to change. What you do about your
drinking is up to you."
Advice To Change. In some types of brief intervention,
professionals give patients explicit advice to reduce or stop drinking (8,24).
While expressing concern about the patient's current drinking and the related
health risks, the physician may discuss guidelines for "low-risk" drinking
(22).
Menu of Ways To Reduce Drinking. Health professionals providing
brief intervention may offer patients a variety of strategies from which to
choose. These may include setting a specific limit on alcohol consumption;
learning to recognize the antecedents of drinking and developing skills to avoid
drinking in high-risk situations; planning ahead to limit drinking; pacing one's
drinking (e.g., sipping, measuring, diluting, and spacing drinks); and learning
to cope with the everyday problems that may lead to drinking (e.g., 19,25,26).
Health care professionals often give their patients self-help materials to
present such strategies and to help them carry these strategies out (e.g.,
11,18,27,28). Self-help materials often include drinking diaries to help
patients monitor their abstinent days and the number of drinks consumed on
drinking days (e.g., 18,21), record instances when they are tempted to drink or
experience social pressure to drink, and note the alternatives to drinking that
they use (29). When working with alcohol-dependent patients, abstinence, rather
than reduced drinking, is the goal of brief intervention.
Empathetic Counseling Style. A warm, reflective, and
understanding of delivering brief intervention is more effective than an
aggressive, confrontational, or coercive (4). Miller and Rollnick (30)
found that when they used an empathetic counseling , patients' drinking was
reduced by 77 percent, as opposed to 55 percent when a confrontational approach
was used.
Self-Efficacy or Optimism of the Patient. Health professionals
delivering brief intervention commonly encourage patients to rely on their own
resources to bring about change and to be optimistic about their ability to
change their drinking behavior (e.g., 8,9). Brief intervention often includes
motivation-enhancing techniques (e.g., eliciting and reinforcing self-motivating
statements, such as "I am worried about my drinking and want to cut back," and
emphasizing the patient's strengths) to encourage patients to develop,
implement, and commit to plans to stop drinking (e.g., 9,31).
Establishing a Drinking Goal. Patients are more likely to
change their drinking behavior when they are involved in goal setting (30,32).
The drinking goal usually is negotiated between the patient and physician and
may be presented in writing as a prescription from the doctor or as a contract
signed by the patient (e.g., 1).
Followup. The health care professional continues to follow up
on the patient's progress and provide ongoing support. Followup may take the
form of telephone calls from office staff, repeat office visits, or repeat
physical examinations or laboratory tests (e.g., 1,17,33).
Timing. Much of the research investigating the relationship
between an individual's readiness to change and actual behavior change is based
on studies of smoking cessation. Research findings have been applied to reducing
drinking (5,6). Individuals are most likely to make behavior changes when they
perceive that they have a problem (34,35) and when they feel they can change
(36). Some patients may not be ready to change when brief intervention begins,
but may be ready when they experience an alcohol-related illness or injury
(34,35,37). Because a patient's readiness to change appears to be a significant
predictor of changes in drinking behavior (38), it is important to assess
patients' readiness to change when beginning a brief intervention. Rollnick and
colleagues (39) created a 12-question "readiness to change" questionnaire for
use in matching intervention techniques with a given patient's stage of
readiness to change.
A few studies indicate that matching the type of brief intervention to the
patient's readiness to change may be important. Among patients highly motivated
to reduce their drinking and confident that they could change on their own, 77
percent decreased their drinking when given a self-help manual with specific
instructions, compared with 28 percent who were given materials with only
general advice (40). For patients with little motivation to change, Heather and
colleagues (38) found that motivational interviewing was more effective than
specific instructions.
Effectiveness of Brief Intervention
For non-alcohol-dependent patients. Many studies suggest that brief
intervention can help non-alcohol-dependent patients reduce their drinking
(e.g., 1,17,18). In a meta-analysis of 32 brief intervention studies, Bien and
colleagues (4) reported that the average positive change observed for
intervention groups was about 27 percent. Positive changes were often observed
for control groups, suggesting that the assessment of drinking behavior and
related problems may, in itself, have led motivated patients to alter their
drinking behavior.
For Alcohol-Dependent Patients. Other studies have examined the
effectiveness of brief intervention for motivating alcohol-dependent patients to
enter long-term alcohol treatment. Among alcoholics identified in an emergency
care setting, 65 percent of those receiving brief counseling kept a subsequent
appointment for specialized treatment, compared with 5 percent of those who did
not receive counseling (7).
Some studies conducted among alcohol-dependent patients have found that brief
intervention is as effective as more extensive treatment approaches used in
specialized alcohol treatment settings (8,9,41,42). Edwards and colleagues (8)
compared the effectiveness of one session giving brief advice to stop drinking
with standard alcohol treatment among 100 alcohol-dependent men. The brief
advice emphasized personal responsibility to stop drinking and encouraged group
members to return to work and improve their marriages. Group members also
received a monthly followup telephone call. The group receiving standard alcohol
treatment was admitted for an average of 3 weeks' inpatient alcoholism
treatment, attended an average of ten 30-minute psychiatric outpatient
counseling sessions, and received monthly followup visits. One year later, both
groups reported a 40-percent decrease in alcohol-related problems. After 2
years, patients with less severe problems were more likely to report improvement
if they received brief intervention than if they received intensive treatment.
However, patients with more severe problems were more likely to report
improvement if they received intensive treatment (43).
Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity)
compared the effects of four 1-hour sessions of motivational enhancement therapy
(MET) with 12 sessions of 12-step facilitation therapy and 12 sessions of
cognitive-behavioral coping skills therapy in more than 1,500 alcohol-dependent
patients (9). (Although MET can be considered a brief intervention because it
consisted of only four sessions, it is more intensive than other brief
interventions.) Both 1 year and 3 years after the intervention, participants in
all three groups reported drinking less often and consuming fewer drinks per
drinking day compared with their drinking behavior before treatment (9,42) (see
Alcohol Alert No. 36, "Patient-Treatment Matching" [44]).
In summary, variations of brief intervention have been found effective for
helping non-alcohol-dependent patients reduce or stop drinking, for motivating
alcohol-dependent patients to enter long-term alcohol treatment, and for
treating some alcohol-dependent patients.
Brief Intervention for Alcohol Problems--A Commentary by
NIAAA Director
Enoch Gordis, M.D.
The finding that brief intervention can be an effective means of intervening
in alcohol problems adds an important tool to the clinician's repertoire of
treatment options. It is an especially attractive option, because it can be used
in primary care settings with minimum disruption to office routine and patient
care. However, the evidence of its effectiveness and low cost may lead to the
conclusion--particularly in today's managed-care environment--that it is always
possible to substitute brief intervention for more specialized care. This would
be a mistake. Brief intervention is not one therapy but several different types
of treatment interventions, with differences in the types of patients who can
benefit from it, the time required to administer the intervention, and the cost.
Thus, requiring brief intervention in lieu of other types of therapy without
specifying the type of intervention or the patients for whom it is best suited
might help some, but certainly not all, patients with alcohol problems.
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1The U.S. Department of Agriculture and the U.S. Department of Health
and Human Services define moderate drinking as no more than two drinks per day
for men and no more than one drink per day for women. A standard drink is 12
grams of pure alcohol, which is equal to one 12-ounce bottle of beer or wine
cooler, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits (3).
2These and other instruments are available on NIAAA's World Wide Web site at http://www.niaaa.nih.gov
All material contained in the Alcohol Alert is in the
public domain and may be used or reproduced without permission from NIAAA.
Citation of the source is appreciated.
Copies of the Alcohol Alert are available free of charge
from the National Institute on Alcohol Abuse and Alcoholism Publications
Distribution Center, P.O. Box 10686, Rockville, MD 20849-0686.
Full text of this publication is available on NIAAA's World Wide Web site at http://www.niaaa.nih.gov
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