Brief interventions for alcohol problems: factors that facilitate implementation

Alcohol Research & Health, Wntr, 2004 by Anne Moyer, John W. Finney

Brief interventions are gaining favor as a means of addressing the problems associated with hazardous and harmful drinking. Brief interventions commonly target people whose levels or patterns of use are not diagnosable as alcohol abuse or dependence. These interventions usually are delivered by professionals who do not specialize in alcoholism treatment, and they include treatment elements designed to encourage people to alter their alcohol use without creating resistance. As evidence mounts regarding the efficacy of these interventions, attention has turned to implementing them successfully. New modes of delivery, such as via computers, the Internet, and interactive multimedia presentations, may help to surmount some of the challenges of wide dissemination, such as strains on expertise, time, and resources. KEY WORDS: harmful drinking; hazardous drinking; risk assessment; intervention (persuasion to treatment); prevention; intervention process and procedures; brief intervention; motivational interviewing; counseling; peer counseling; normative education; computer-assisted instruction; primary care facility; emergency room; trauma center

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As those in the alcohol field recognize that the problems associated with drinking begin at alcohol consumption levels much lower than those previously thought to warrant treatment, brief interventions have become an important tool in the intervention armamentarium. In addition, the importance of secondary prevention has become more widely acknowledged as research evidence has accumulated regarding the reduction of health care and social costs that may be achieved with brief interventions.

FEATURES OF BRIEF INTERVENTIONS

Brief interventions typically emphasize reducing a person's alcohol consumption to nonhazardous levels and eliminating binge drinking rather than insisting that the person abstain from drinking, although abstinence also may be a welcomed goal. A common aim is to intervene early and target people whose levels of drinking or patterns of use would be considered hazardous or harmful (1) and to reduce problems associated with drinking, such as alcohol-related medical problems, injuries, domestic violence, motor vehicle crashes, arrests, or damage to a fetus. Accordingly, brief interventions do not usually target people whose levels or patterns of drinking meet diagnostic criteria for alcohol abuse or alcohol dependence, although they sometimes may be used to motivate an abusing or dependent drinker to seek more intensive alcohol-related treatment or as a first stage in a "stepped" care model, in which more intensive/extensive treatment would be provided if brief intervention failed.

People drinking at levels thought to be suitable for brief interventions often are identified at their primary care facility when they are screened during a routine health care visit, or at the hospital during a stay on a medical unit for a different condition. Alternatively, people who could benefit from brief interventions can be identified by an event precipitated by their problematic alcohol use (e.g., an emergency room visit for alcohol-related injuries or an arrest for driving while intoxicated), or they may be in situations in which drinking is particularly harmful (e.g., while pregnant). Clinicians and others who are in the position to give brief interventions could capitalize on these occasions when people may be particularly receptive to advice to alter their drinking. (See the textbox for a summary of settings in which people can be assessed for alcohol problems.)

Often, a nonspecialist authority figure whom the patient may already trust or feel comfortable being treated by--such as a physician, a nurse or physician's assistant in a primary care setting, or a nurse or physician's assistant on a medical unit--delivers the brief intervention. (The sidebar "Implementing and Disseminating Brief Interventions" discusses the effect of professionals' attitudes toward delivering brief interventions.) Brief interventions usually involve individualized feedback and counseling based on an assessment that the patient is at risk for harmful drinking. Such feedback in itself may encourage some hazardous or harmful drinkers to reduce their alcohol intake.

Brief interventions also commonly use client-centered approaches, which are designed to motivate people who may resist suggestions to moderate their alcohol intake or may help to reach people who do not believe

they are drinking in a harmful or hazardous way. Motivational interviewing (Miller and Rollnick 1991) is an important client-centered technique that uses empathy and warmth rather than confrontation to encourage people to decide for themselves to change. In addition to offering encouragement or advice to change, clinicians providing brief interventions typically help their patients establish goals and provide specific skill-building strategies they can use in modifying their drinking behavior. Clinicians can include supplemental materials, such as pamphlets, manuals, or workbooks, to help convey and reinforce these strategies. After this initial contact, clinicians can provide followup with additional assessment and advice to clarify and bolster the strategies and goals. If a brief intervention is not successful in motivating a patient to reduce alcohol consumption, the clinician then can recommend that the person seek more extensive treatment.