Brief Intervention Therapies for Alcohol Misuse in Primary Care Settings by Dr. John Lyne, Dr. Conall Larkin and Dr. Colin O' Gara

Brief intervention therapy is an underutilised tool in managing alcohol related problems. It is a simple form of intervention which can be used in many settings, including primary care, inpatient, and Emergency Department settings. It may be used in those at risk of harmful drinking or those already experiencing alcohol related problems. General Practitioners will see numerous patients who they may identify as being at risk for alcohol problems. Studies have shown that up to 20 per cent of patients presenting to general practices may report hazardous drinking levels, and these patients are at risk for developing more severe addiction problems (Fleming et al 1998).
Harmful drinking and binge drinking is becoming more widespread in Irish culture today. A recent eurobarometer report on attitudes towards alcohol published in March 2007, suggested that Ireland had the highest rate of binge drinkers in the EU with 34% of people in Ireland reporting having 5 or more drinks on average at one sitting, which was more than 3 times the EU average of 10%. Another report carried out by the Institute of alcohol studies in London, on behalf of the European Commission, suggested that a higher proportion of income was spent on alcohol in Ireland than in any other EU country. It has become a serious public health concern in Ireland today.
Brief intervention therapy consists of an assessment of alcohol intake, information on the consequences of harmful drinking, and giving clear advice for the individual. Numerous trials have indicated that such therapies can significantly reduce patient's drinking levels, and also that brief intervention therapy is better than no intervention. Evidence would suggest that the effect of this therapy may last for at least 2-4 years, and that subsequent booster sessions may give benefit for longer periods of time. Evidence also suggests that brief intervention therapy may reduce alcohol related problems among harmful drinkers, and possibly alcohol related mortality.

 Screening

The first step of brief intervention therapy is identifying those at risk for developing alcohol problems. The CAGE questionaire is a commonly used screening tool for this purpose and consists of 4 questions

1. Do you feel you should Cut down?
2. Do you get Annoyed when people talk about your drinking?
3. Do you feel Guilty about your drinking?
4. Do you heve Eye-openers?

2 positive responses indicate a positive result, and that further assessment is warranted.

This tool may be more useful for screening those with more severe alcohol problems. The WHO has more recently developed a 10 item AUDIT (Alcohol Use Disorders Identification Test) for use in primary care settings, which may detect up to 92 percent of harmful drinkers, and 94 pecent who drink above the recommended levels (Saunders et al 1993). Other indicators for harmful use may be abnormal biochemical results (LFT esp. GGT, MCV, high cholesterol), or a history of trauma with suspicion of alcohol involvement.

Brief Intervention Methods

Once it has been established that the patient may be at risk, the brief intervention may be carried out. The following FRAMES (Feedback, Responsibilty, Advice, Menu of change, Empathy, Self-efficacy) acronym was first described by Miller and Sanchez in 1994.

1. Direct Feedback:
Feedback is given to the patient regarding concerns around their alcohol consumption, based on their drinking pattern, and preferably linking it into some health concern that the patient already has (eg. gastritis, high Blood Pressure etc.). A patient's readiness to reduce alcohol consumption is more likely if they perceive themselves that there is a problem, and linking alcohol consumption to a physical complaint can be an effective motivating factor.

2. Patient Responsibility
It is often more effective if the patient themselves are given responsibility for their actions, rather than using a confrontational type of approach. So, for example, it may be best to say that they cannot be forced to change, and that it is up to them whether they take the advice or not.

3. Advice
The patient is advised to reduce or stop alcohol consumption in this step. This advice must be clear for the patient, and without ambivalence.

4. Menu of change
The next step is to help the patient see a realistic way of changing their behaviours, as the patient may not be aware of how best to reduce alcohol consumption. A number of suggestions may be made such as:
-Setting limits on alcohol consumption
-Advice on how to avoid high risk situations (eg. driving to events where alcohol may be involved)
-Not getting into rounds with others
-Rehearsing what to say when offered a drink they don't want
-Pacing their drinking
-Learning to deal with stressful situations without alcohol

5. Empathy
All advice should be given in an empathic manner, and without judgement. A warm empathic approach has been shown to be more effective than an aggressive, confrontational style. Advice on setting goals may be effective at this time also. It is important to be realistic when setting goals with patients, and the patient's readiness to change should be taken into account. Sometimes the patient may not be willing to change their behaviours and this may have to be accepted.

6. Self efficacy
This involves the practitioner trying to promote optimism in the patient regarding the new changes. Brief intervention therapies are known to be more effective if the patient has confidence in their ability to carry out the change.

Follow up is another aspect of brief intervention therapy and when the patient represents to the clinic, alcohol issues should be discussed once again. In some cases, another scheduled appointment, or further phone contact from a practitioner or nurse, may be effective for the patient. If the patient was unwilling to change last time, further reinforcement on subsequent visits may persuade the patient.

It should be noted that most research carried out on brief intervention techniques, relate to patients who are not dependent or have only mild dependence, and this may be where it is most effective. Those with more severe alcohol dependence should be encouraged to remain abstinent, and referral to a specialist service for more intensive treatment may be appropriate.

Conclusion

Brief intervention therapy can be a useful tool in the primary care setting at alleviating an ever growing problem in Irish society. It's use in this setting has the potential to have a huge public health impact on harmful drinking in Ireland. Primary care settings can be an ideal situation where brief intervention may prove very effective, particularly if the patient has a medical problem related to drinking. It is a simple, time and cost efficient method of reducing alcohol related problems. It may be more suitable for some patients than others, but numerous studies have shown it to be an effective means of preventing future problems, and have proven it to be superior than simply giving advice to patients.

 
AUDIT (Alcohol Use Disorders Identification Test) Questionnaire
Keep track of the number of points assigned to each answer and add up the numbers at the end of the questionnaire.
1. How often do you have a drink containing alcohol?
• 0 – Never
• 1 – Monthly or less
• 2 – 2-4 times per month
• 3 – 2-3 times per week
• 4 – 4 or more times per week
2. How many drinks do you have on a typical day when you are drinking?
• 0 – None
• 1 – 1 or 2
• 2 – 3 or 4
• 3 – 5 or 6
• 4 – 7-9
3. How often do you have 6 or more drinks on one occasion?
• 0 – Never
• 1 – Less than monthly
• 2 – Monthly
• 3 – Weekly
• 4 – Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
• 0 – Never
• 1 – Less than monthly
• 2 – Monthly
• 3 – Weekly
• 4 – Daily or almost daily
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
• 0 – Never
• 1 – Less than monthly
• 2 – Monthly
• 3 – Weekly
• 4 – Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
• 0 – Never
• 1 – Less than monthly
• 2 – Monthly
• 3 – Weekly
• 4 – Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
• 0 – Never
• 1 – Less than monthly
• 2 – Monthly
• 3 – Weekly
• 4 – Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
• 0 – Never
• 1 – Less than monthly
• 2 – Monthly
• 3 – Weekly
• 4 – Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
• 0 – Never
• 2 – Yes, but not in the last year
• 4 – Yes, during the last year
10. Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
• 0 – Never
• 2 – Yes, but not in the last year
• 4 – Yes, during the last year
A total score of 8 or higher is considered positive for a possible alcohol use disorder.