brief interview.pdf

8/17/2019 Brief Interview.pdf

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World Health Organization

B R I E F

I N T E R V E N T I O N

For Hazardou s andHarm ful DrinkingA M anual f or Use in Prim ary Care

Thom as F. Babo rJohn C. Higg ins-Bidd le

WHO/MSD/MSB/01.6b

Original: English

Dist r ibut ion: General

Department of Menta l Health a nd Substance Dependence


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Department of Ment a l Health a nd Substance Dependence

World Health Organization

B R I E F

I N T E R V E N T I O N

For Hazardous andHarmful Drinking

A M anual fo r Use in Prim ary Care

Thoma s F. BaborJohn C. Higgins-Biddle

WHO/MSD/MSB/01.6bOriginal: EnglishDist r ibut ion: General


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TABLE OF CONTENTS I3

Table of Cont ent s

Introduction

Co ncep ts a nd Terms

Ro les a nd Respon sibilities of Prima ry Hea lth Ca re

SBI: A Risk Ma na g eme nt a nd

Ca se Finding Appro a ch

Alco ho l Ed uca tio n fo r Lo w -Risk Drinkers,

Absta iners a nd Others

Simple Ad vice f o r Risk Zone II Drinke rs

Brief Counselling for Risk Zone III Drinkers

Ref erra l fo r Risk Zo ne IV Drinkers w ith

Prob a ble Alcoh ol Depend ence

Appendix

A. Pat ient Educa t ion Brochure

A Guid e t o Low -Risk Drinking

B. Self-Help Booklet

C. Training Resources

References

4

5

7

11

14

17

23

27

30

32

38

47

49


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Brief interventions have becom e increas-

ingly valuable in the m anagem ent of

individuals w ith alcohol-related problem s.

Because brief interventions are low in cost

and have proven to be effective across the

spectrum of alcohol problem s, health w ork-

ers and policym akers have increasingly

focused on them as tools to fill the gap

betw een prim ary prevention efforts and

m ore intensive treatm ent for persons w ithserious alcohol use disorders. A s described

in this m anual, brief interventions can serve

as treatm ent for hazardous and harm ful

drinkers, and as a w ay to facilitate referral

of m ore serious cases of alcohol depen-

dence to specialized treatm ent.

This m anual is w ritten to help prim ary care

health w orkers –physicians, nurses, com -

m unity health w orkers, and others –to deal

w ith persons w hose alcohol consum ption

has becom e hazardous or harm ful to their

health. Its aim is to link scientific research

to clinical practice by describing how to

conduct brief interventions for patients

w ith alcohol use disorders and those at risk

of developing them . The m anual m ay also

be useful for social service providers, people

in the crim inal justice system , m ental healthw orkers, and anyone else w ho m ay be

called on to intervene w ith a person w ho

has alcohol-related problem s. W hatever the

context, brief interventions hold prom ise for

addressing alcohol-related problem s early in

their developm ent, thus reducing harm to

patients and society.

W ith the com panion publication on the

A lcohol U se D isorders Identification Test

(A U D IT)1, these m anuals describe a com pre-

hensive approach to alcohol screening and

In t roduct ion

brief intervention (SBI) that is designed to

im prove the health of populations and

patient groups as w ell as individuals. O nce

a system atic screening program is initiated,

the SBI approach show s how health w ork-

ers can use brief interventions to respond

to three levels of risk: hazardous drinking,

harm ful drinking, and alcohol dependence.

Brief interventions are not designed to treatpersons w ith alcohol dependence, w hich

generally requires greater expertise and

m ore intensive clinical m anagem ent. The

interested reader is referred to sources list-

ed at the end of this m anual for inform a-

tion about the identification and m anage-

m ent of alcohol dependence2, 3.

N evertheless, the SBI approach described in

these pages specifies an im portant role for

prim ary care practitioners in the identifica-

tion and referral of persons w ith probable

alcohol dependence to appropriate diag-

nostic evaluation and treatm ent.

In addition, this m anual describes how pri-

m ary care health w orkers can use SBI as an

efficient m ethod of health prom otion and

disease prevention for the entire population

of patients they see in their com m unities.

By taking a few m inutes follow ing screen-

ing to advise low -risk drinkers and abstain-

ers about the risks of alcohol, prim ary care

w orkers can have a positive im pact on the

attitudes and norm s that sustain hazardous

and harm ful drinking in the com m unity.

4 IBRIEF INTERVENTION FOR HAZA RDOUS AN D HARM FUL DRINKING


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Anum ber of term s and concepts are

used here that m ay be new to prim ary

health care health w orkers. Fortunately,

the term s are easy to understand and are

sufficiently free of technical jargon to be

used w ith patients. M any of these term s

have now been incorporated into the

nom enclature of the tenth revision of

International C lassification of Diseases

(IC D -10)4. A s IC D -10 becom es adoptedinto health care system s throughout the

w orld, this m anual w ill provide a practical

w ay to use its term inology in everyday

clinical practice.

In any discussion of alcohol-related prob-

lem s, it is im portant to distinguish am ong

“use,” “m isuse,” and “dependence.” The

w ord use refers to any ingestion of alco-

hol. W e use the term low risk alcohol useto refer to drinking that is w ithin legal

and m edical guidelines and is not likely to

result in alcohol-related problem s. A lcohol

m isuse is a general term for any level of

risk, ranging from hazardous drinking to

alcohol dependence.

A lcohol dependence syndrom e is a cluster

of cognitive, behavioural, and physiologi-

cal sym ptom s. A diagnosis of dependence

should only be m ade if three or m ore of

the follow ing have been experienced or

exhibited at som e tim e in the previous

tw elve m onths:

a strong desire or sense of com pulsion

to drink;

difficulties in controlling drinking in

term s of onset, term ination, or levels ofuse;

a physiological w ithdraw al state w hen

alcohol use has ceased or been

reduced, or use of alcohol to relieve or

avoid w ithdraw al sym ptom s;

evidence of tolerance, such that

increased doses of alcohol are required

to achieve effects originally produced by

low er doses;

progressive neglect of alternative plea-sures or interests because of alcohol

use;

continued use despite clear evidence of

harm ful consequences.

Because alcohol m isuse can produce m ed-

ical harm w ithout the presence of depen-

dence, IC D -10 introduced the term harm-

ful use into the nom enclature. Thiscategory is concerned w ith m edical or

related types of harm , since the purpose

of IC D is to classify diseases, injuries, and

causes of death. H arm ful use is defined as

a pattern of drinking that is already caus-

ing dam age to health. The dam age m ay

be either physical (e.g., liver dam age from

chronic drinking) or m ental (e.g., depres-

sive episodes secondary to drinking).

H arm ful patterns of use are often criti-

cized by others and are som etim es associ-

ated w ith adverse social consequences of

various kinds. H ow ever, the fact that a

fam ily or culture disapproves drinking is

not by itself sufficient to justify a diagno-

sis of harm ful use.

A related concept not included in IC D -10,but nevertheless im portant to screening, is

hazardous use. H azardous use is a pattern

CONCEPT AND TERMS I5

Con ce pt s a nd Te rm s


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of alcohol consum ption carrying w ith it a

risk of harm ful consequences to the drinker.

These consequences m ay be dam age to

health, physical or m ental, or they m ay

include social consequences to the drinker

or others. In assessing the extent of that

risk, the pattern of use, as w ell as other

factors such as fam ily history,should be

taken into account.

W hile it is im portant to diagnose a

patient’s condition in term s of harm ful

use or dependence, it is equally im portant

to understand the pattern of drinking

that produces risk. Som e patients m ay

drink in large quantities on particular

occasions, but m ay not drink m ore than

recom m ended am ounts on a regular,

w eekly basis. Such drinking to the point

of intoxication presents an acute form of

risk involving injuries, violence, and loss of

control affecting others as w ell as them -

selves. O ther patients m ay drink exces-

sively on a regular basis and, having

established an increased tolerance for

alcohol, m ay not dem onstrate m arked

im pairm ent at high blood alcohol levels.

C hronic excessive consum ption presents

risks of long-term m edical conditions suchas liver dam age, certain cancers, and psy-

chological disorders. A s w ill becom e obvi-

ous in the rem ainder of this m anual, the

purpose of m aking distinctions am ong

patterns of drinking and types of risk is

to m atch the health needs of different

types of drinkers w ith the m ost appropri-

ate interventions. Because of the heavy

dem ands on busy health w orkers in pri-

m ary care, interventions need to be brief.

Brief intervent ions are those practices that

aim to identify a real or potential alcohol

problem and m otivate an individual to do

som ething about it.

In m any cultures the labels or term s

applied to excessive drinkers carry highly

negative connotations. The distinctions

m ade here about types of m isuse on a

broad continuum are seldom reflected inpopular concepts and term inology. To

avoid arousing resistance and defensive-

ness, it is best w herever possible to

describe patients’alcohol use and drink-

ing behaviours rather than to use person-

al labels. H ence, discussion of hazardous

drinking or alcohol dependence is prefer-

able to labeling a patient as a binge

drinker or an alcoholic. This w ill allow

patients to focus on changing their drink-

ing behaviour w ithout feeling defensive

about the term s being applied to them .



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Prim ary care health w orkers are in a

unique position to identify and intervene

w ith patients w hose drinking is hazardous

or harm ful to their health5. They m ay also

play a critical role in leading patients w ith

alcohol dependence to enter treatm ent.

Patients have confidence in the expertise

of health w orkers and expect them to be

interested in the health effects of drink-

ing. The inform ation provided by healthw orkers is often critical not only in the

m anagem ent of disease but also in its

prevention. Prim ary health care is the m ain

vehicle for the delivery of health services

in m any parts of the w orld, w ith m ost of

the w orld’s population consulting a physi-

cian or other health w orker at least once

a year. Because patients trust the inform a-

tion they receive from health w orkers,

advice about alcohol use is likely to be

taken seriously w hen given in the context

of a m edical or preventive health consul-

tation. M oreover, the prim ary care setting

is ideal for continuous m onitoring and

repeated intervention.

U nfortunately, som e prim ary care health

w orkers are reluctant to screen and coun-

sel patients in relation to alcohol use.A m ong the reasons m ost often cited are

lack of tim e, inadequate training, fear of

antagonizing patients, the perceived

incom patibility of alcohol counseling w ith

prim ary health care, and the belief that

“alcoholics” do not respond to interven-

tions. Each of these reasons constitutes a

m isconception that is contradicted by evi-

dence as w ell as logic.

La c k o f T ime

A com m on concern expressed by health

w orkers is that Screening and Brief

Intervention (SBI) w ill require too m uch

tim e. G iven the dem ands of a busy

healthcare practice, it is reasonable to

argue that the health w orker’s first duty

is to attend to the patient’s im m ediateneeds, w hich are typically for acute care.

But such an argum ent fails to give appro-

priate w eight to the im portance of alcohol

use to the health of m any patients and

overestim ates the tim e required. Because

alcohol use is a leading contributor to

m any health problem s encountered in

prim ary care, SBI can often be delivered

in the course of routine clinical practice

w ithout requiring significantly m ore tim e.

A brief self-report screening test can be

distributed w ith other form s patients are

asked to com plete in the w aiting room ,

or the questions can be integrated into a

routine m edical history interview . Either

w ay, screening requires only 2-4 m inutes.

Scoring and interpretation of the screen-

ing test takes less than a m inute. O nce

the screening results are available, only asm all proportion (5% -20% ) of patients in

prim ary care are likely to require a brief

intervention. For those w ho screen posi-

tive, the intervention for m ost patients

requires less than five m inutes. If brief

counseling is required, up to 15 m inutes

is recom m ended to review the self-help

booklet described in this m anual and to

develop a plan for m onitoring or referral.

ROLES AN D RESPON SIBILITIES OF PRIM ARY HEALTH CARE I7

Role s a nd Re spo nsibi l i t iesof Pr ima ry Heal t h Care


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I n a d e q u a t e Tr a i n i n g

M any health w orkers feel that their train-

ing is not adequate to screen and counsel

patients in relation to alcohol use. W hile

it is true that professional education is

often inadequate w here alcohol is con-

cerned, there are now am ple opportuni-

ties for training in use of new screeningand intervention techniques. N ot only is

training relatively sim ple and easy, it is

also possible to train one person in a busy

clinic to take responsibility for alcohol

screening, thereby reducing the burden

on other m em bers of the health care

team . This m anual can also help in train-

ing health w orkers. O ther resources are

listed in A ppendix C .

Fe a r o f A n t a g o n i zi n gPa t i e n t s o v e r a S e n si t i v ePersonal Issue

A nother com m on m isconception about

SBI is that patients w ill becom e angry if

questioned about their drinking, or they

w ill deny having problem s and resist anyattem pts to change their drinking behav-

iour. W hile denial and resistance are

som etim es encountered from persons

w ith alcohol dependence, harm ful and

hazardous drinkers are rarely uncoopera-

tive. O n the contrary, the experience

gained from num erous research studies

and clinical program s indicates that

alm ost all patients are cooperative, and

m ost are appreciative w hen health w ork-

ers show an interest in the relationship

betw een alcohol and health. In general,

patients perceive alcohol screening and

brief counseling as part of the health

w orker’s role, and rarely object w hen it is

conducted according to the procedures

described in this m anual.

A l co h o l i s n o t a M a t t e r t h a t

N e e d s t o b e A d d r e sse d i nP r i m a r y H e a l t h Ca r e

This m isconception is contradicted by a

m assive am ount of evidence show ing

how alcohol is im plicated in a variety of

health-related problem s6. These problem s

not only affect the health of the individ-

ual, but also the health of fam ilies, com -

m unities, and populations. In general,

there is a dose-response relationshipbetw een alcohol consum ption and a vari-

ety of disease conditions, such as liver cir-

rhosis and certain cancers (e.g., m outh,

throat, and breast). Sim ilarly, the m ore

alcohol an individual consum es, the

greater the risk of injuries, autom obile

crashes, w orkplace problem s, dom estic

violence, drow ning, suicide, and a variety

of other social and legal problem s. A s

w ith secondhand sm oke, excessive drink-ing has secondary effects on the health

and w ellbeing of persons in the drinker’s

im m ediate social environm ent.

U nintentional injuries, increased fam ily

health care costs, and psychiatric prob-

lem s are som e of the unintended conse-

quences of harm ful drinking. Thus, if pri-

m ary health care involves the prevention

and treatm ent of such com m on physical

and m ental conditions, it m ust address

their causes in alcohol m isuse.



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“ Alcohol ics” d o n o tRe sp o n d t o P r i m a r y C a r eI n t e r v e n t i o n s .

H ealth w orkers w ho confuse all form s of

excessive drinking w ith alcohol depen-

dence often voice this m isconception.

A lcohol m isuse includes m uch m ore than

alcohol dependence. A lcohol dependenceaffects a sm all but significant proportion

of the adult population in m any countries

(3% -5% in industrialized nations), but

hazardous and harm ful drinking generally

affect a m uch larger portion of the popu-

lation (15% -40% ). The purpose of a sys-

tem atic program of SBI in prim ary care

settings is tw o-fold. It w ill identify and

refer persons w ith alcohol dependence at

an early stage in their drinking career,

thereby preventing further progression of

dependence. A second purpose is to iden-

tify and help hazardous and harm ful

drinkers w ho m ay or m ay not develop an

alcohol dependence syndrom e, but

w hose risk of serious alcohol-related harm

can be reduced. C ontrary to popular m is-

conceptions, SBI is effective w ith both

populations.

Persons w ith alcohol dependence respond

w ell to form al treatm ent and to the kinds

of com m unity-based assistance provided

by m utual help societies7, 8. But these

sam e individuals often need to be con-

vinced that they have a problem w ith

respect to alcohol and need encourage-

m ent to seek help. This is an im portant

responsibility of prim ary care health w ork-

ers, w ho are in an ideal position to use

their expertise, know ledge, and respected

role as gatekeepers to refer alcohol

dependent patients to the appropriate

type of care.

C ontrary to the belief that alcohol-related

problem s cannot be m anaged in prim ary

care, hazardous and harm ful drinkers

respond w ell to prim ary care intervention

(see Box 1). U nlike persons w ith alcohol

dependence, w ho should be referred to

specialist care, hazardous and harm ful

drinkers should be given sim ple advice

and brief counseling, respectively. These

brief interventions have been show n in

num erous clinical trials to reduce the

overall level of alcohol consum ption,

change harm ful drinking patterns, prevent

future drinking problem s, im prove health,

and reduce health care costs9, 10, 11, 12

.

Prim ary care providers are experienced in

treating patients w ith diabetes and hyper-

tension, w ho require initial identification

through screening, counseling about

behavioural change, and on-going sup-

port. This expertise w ill prove useful in

providing sim ilar help to hazardous and

harm ful drinkers.

S u m m a r y

The reluctance of prim ary care health

w orkers to conduct alcohol screening and

brief intervention is often based on

assum ptions about the difficulty of the

task, the tim e required, the skills needed,

and the response of the patient. U pon clos-

erexam ination, m ost of these perceived

barriers to SBI are either m isconceptions

ROLES AN D RESPON SIBILITIES OF PRIM ARY HEALTH CARE I9


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or m inor challenges that can be easily

overcom e. Perhaps m ore difficult to

address, how ever, is the health w orkers’

ow n attitudes tow ard and personal use of

alcohol. G iven the obligation to provide

the best possible health care to patients,

im plem enting a trial program m e of SBI

m ay provide the best opportunity to con-

vince skeptics that it is feasible, efficient,

and effective.

1 0 IBRIEF INTERVENTION FOR HAZA RDOUS AN D HARM FUL DRINKING

B o x 1

Th e Ev i d e n ce f o r Br i e f I n t e r v e n t i o nD uring the past 20 years, there have been num erous random ized clinical trials of brief

interventions in a variety of health care settings. Studies have been conducted in

A ustralia, Bulgaria, M exico, the U nited Kingdom , N orw ay, Sw eden, the U nited States,

and m any other countries. Evidence for the effectiveness of brief interventions has been

sum m arized in several review articles, including the follow ing:

In one of the earliest review articles, Bien, et al.9 considered 32 controlled studies

involving over 6,000 patients, finding that brief interventions w ere often as effective

as m ore extensive treatm ents. “There is encouraging evidence that the course of

harm ful alcohol use can be effectively altered by w ell-designed intervention strategies

w hich are feasible w ithin relatively brief-contact contexts such as prim ary health care

settings and em ployee assistance program s.”

Kahan, et al.10 review ed 11 trials of brief intervention and concluded that, w hile fur-

ther research on specific issues is required, the public health im pact of brief interven-

tions is potentially enorm ous. “G iven the evidence for the effectiveness of brief inter-

ventions and the m inim al am ount of tim e and effort they require, physicians are

advised to im plem ent these strategies in their practice.”

Tw elve random ized controlled trials w ere review ed by W ilk, et al.11, w ho concluded that

drinkers receiving a brief intervention w ere tw ice as likely to reduce their drinking over 6

to 12 m onths than those w ho received no intervention. “Brief intervention is a low -cost,

effective preventive m easure for heavy drinkers in outpatient settings.”

M oyer, et al.12 review ed studies com paring brief intervention both to untreated control

groups and to m ore extended treatm ents. They found “further positive evidence”for

the effectiveness of brief intervention, especially am ong patients w ith less severe

problem s. C autioning that brief intervention should not substitute for specialist treat-

m ent, they suggested that they m ight w ell serve as an initial treatm ent for severely

dependent patients seeking extended treatm ent.


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Box 2 are presented as general guidelines

for assigning risk levels based upon A U D IT

scores. They m ay serve as a basis for m aking

clinical judgm ents to tailor interventions

to the particular conditions of individual

patients. This approach is based upon the

prem ise that higher A U D IT scores are

generally indicative of m ore severe levels

of risk. The cut-off points, how ever, are

no t based on sufficient evidence to benorm ative for all groups or individuals.

C linical judgm ent m ust be used to identify

situations in w hich the total A U D IT score

m ay not represent the full risk level, e.g.,

w here relatively low drinking levels m ask

significant harm or signs of dependence.

N evertheless, these guidelines can serve

as a starting point for an appropriate

intervention. If a patient is not successful

at the initial level of intervention, follow -

up should yield a plan to step the patient

up to the next level of intervention. Readers

are encouraged to consult carefully the

com panion m anual1 on the A U D IT and toconsider its recom m endations for adapting

the scoring to national policies, local set-

tings, gender differences, and other issues

that cannot be addressed here.


B o x 2

Risk Le v e l I n t e r v e n t io n AUD I T Sco re *

Zone I A lcohol Education 0-7

Zone II Sim ple A dvice 8-15

Zone III Sim ple A dvice plus 16-19

Brief Counseling

and C ontinued M onitoring

Zone IV Referral to Specialist 20-40

for D iagnostic Evaluation

and Treatm ent

*The A U D IT cut-off score m ay vary slightly depending on the country’s drinking pat-

terns, the alcohol content of standard drinks, and the nature of the screening pro-

gram . C onsult the A U D IT m anual for details. C linical judgm ent should be exercised in

the interpretation of screening test results to m odify these guidelines, especially w henA U D IT scores are in the range of 15-20.


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The first level, Risk Zone I, applies to the

m ajority of patients in m ost countries.

A U D IT scores below 8 generally indicate

low -risk drinking. Although no intervention

is required, for m any individuals alcohol

education is appropriate for several reasons:

it contributes to the general aw areness of

alcohol risks in the com m unity; it m ay

serve as a preventive m easure; it could be

effective for patients w ho have m inim izedthe extent of their drinking on the A U D IT

questions; and it m ight rem ind patients

w ith past problem s about the risks of

returning to hazardous drinking.

The second level, Risk Zone II, is likely to

be encountered am ong a significant pro-

portion of patients in m any countries. It

consists of alcohol use in excess of drink-

ing guidelines. A lthough drinking guide-

lines vary from country to country,

epidem iological data suggest that the

risks of alcohol-related problem s increase

significantly w hen consum ption exceeds

20g of pure alcohol per day, w hich is the

equivalent of approxim ately tw o standard

drinks in m any countries6. A n A U D IT score

betw een 8 and 15 generally indicates

hazardous drinking, but this zone m ayalso include patients experiencing harm

and dependence.

The third level, Risk Zone III, refers to a

pattern of alcohol consum ption that is

already causing harm to the drinker, w ho

m ay also have sym ptom s of dependence.

Patients in this zone m ay be m anaged

by a com bination of sim ple advice, brief

counseling, and continued m onitoring.A U D IT scores in the range of 16-19 often

suggest harm ful drinking or dependence,

for w hich a m ore thorough approach to

clinical m anagem ent is recom m ended.

The fourth and highest risk level, Risk

Zone IV, is suggested by A U D IT scores in

excess

of 20. These patients should be referred

to a specialist (if available) for diagnostic

evaluation and possible treatm ent for

alcohol dependence. H ealth w orkersshould note, how ever, that dependence

varies along a continuum of severity and

m ight be clinically significant even at low er

A U D IT scores. In the follow ing sections, the

clinical m anagem ent of patients scoring in

each of these zones is described in m ore

detail.

SBI : A RISK MA NAGEM ENT AND CASE F INDING APPROACH I1 3


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Patients w ho screen negative on the

A U D IT screening test (i.e., Zone I),

w hether they are low -risk drinkers or

abstainers, m ay nevertheless benefit from

inform ation about alcohol consum ption.

M ost people’s alcohol use varies over

tim e. Thus, a person w ho is drinking

m oderately now m ay increase consum p-

tion in the future. M oreover, alcohol

industry advertising and m edia storiesabout the benefits of alcohol consum p-

tion m ay lead som e non-drinkers to drink

for health reasons and others w ho drink

m oderately to consum e m ore. Therefore,

a few w ords or w ritten inform ation about

the risks of drinking m ay prevent hazardous

or harm ful alcohol use in the future.

Patients should also be praised for their

current low -risk practices and rem inded

that, if they do drink, they should stay

w ithin the recom m ended allow ances.

Inform ation about w hat constitutes a

standard drink is essential to understanding

those lim its. It m ay take less than a m inute

to com m unicate this inform ation and to

ask if the patient has any questions. The

patient education brochure in A ppendix

A can be used for this purpose.

Box 3 provides a sam ple script for prim ary

care providers to illustrate how to m an-

age patients w hose screening test results

are negative.

H o w t o D e a l w i t h Pa t i e n t sw h o a r e C o nce r n e d a b o u tFa m i l y M e m b e r s a n dFr ie nds

W hen the issue of alcohol use is raised

during a prim ary care visit, it is not

unusual for patients to be interested in

this inform ation as a m eans of eitherunderstanding or helping fam ily m em bers

or friends. A ccording to A nderson5, pro-

viding advice to concerned fam ily and

friends is im portant for tw o reasons:

advice m ay help to reduce the stress

that is often experienced by people in

the excessive drinker’s im m ediate social

environm ent; and

these people can play a critical role in

helping to change the drinker’s behaviour.

Prim ary care providers can do at least

three things to help a relative or friend

cope w ith an excessive drinker14:

L i s t e n S y m p a t h e t i c a l l y

The prim ary care provider can ask the

concerned friend or fam ily m em ber to

describe the drinking problem they are

attem pting to deal w ith and its effect on

them . It is im portant to determ ine the

severity of the drinking problem in question

according to the criteria described in this

m anual for hazardous drinking, harm ful

drinking, and alcohol dependence syn-

drom e. This inform ation should be

received confidentially and any questionsor com m ents should be non-judgm ental.


Alcoho l Educat ion f or Low Risk Dr inke rs,Abst ainers and Ot hers


16/53

ALCOHOL EDUCATION I1 5

B o x 3

W h a t t o d o w i t h Pa t i e n t s w h o se S cr e e n i n g Te st Re su l t sa r e N e g a t i v e

P r o v i d e F e e d b a c k a b o u t t h e R e su l t s o f t h e S c r e e n i n g Te s t

Example

“I have looked over the results of the questionnaire you completed a few minutes

ago. If you remember, the questions asked about how much alcoho l you consume,

and whether you have experienced any prob lems in connection w ith your drinking .

From your answers it appears that you are at low risk of experiencing alcoho l-related

prob lems if you cont inue to drink moderately (abstain).”

E d u ca t e Pa t i e n t s a b o u t L o w - R i sk L e v e l sa n d t h e H a z a r d s o f Ex ce e d i n g t h e m

Example “If you do drink, please do not consume more than two drinks per day, and always

make sure that you avoid drinking at least two days of the week, even in small

amount s. It is oft en useful to pay attention t o the number of ‘standard drinks’ you

consume, keeping in mind that one bott le of beer, one glass of w ine, and one drink

of spirits generally cont ain about the same amounts of alcoho l. People who exceed

these levels increase their chances of alcoho l-related health problems like accidents,

injuries, high blood pressure, liver disease, cancer, and heart disease.”

C o n g r a t u l a t e Pa t i e n t s f o r t h e i r A d h e r e n c e t o t h e G u i d e l i n e sExample

“So keep up the good w ork and always try to keep your alcohol consumpt ion below

or w ithin t he low -risk guidelines.”

N o t e

The Patient Education Brochure in Appendix A can be used to provide alcohol education

to low -risk drinkers, placing em phasis on the D rinkers’Pyram id (Panel 2), the standard

drink illustration (Panel 6) and the low -risk drinking guidelines (Panel 5).


17/53

P ro v i d e I n f o r m a t i o n

Inform ation is a form of support.

D epending on the severity of the prob-

lem , copies of the low -risk drinking

brochure in A ppendix A can be provided

as w ell as inform ation about different

kinds of specialized treatm ent.

E n co u r a g e S u p p o r t a n d Jo i n tP r o b l e m - S o l v i n g

Fam ily and friends are often the m ost

im portant influence on a drinker’s decision

to take positive action. They should be

encouraged to speak w ith the problem

drinker individually or as a group to express

their concern, suggest constructive action,

and provide em otional support. Such inter-

ventions should attem pt to set a positivetone, w ithout accusatory, negative state-

m ents or highly charged confrontation.



18/53

W h o i s A p p r o p r i a t ef o r Si m p l e A d v i ce ?

Abrief intervention using sim ple advice

is generally appropriate for patients

w hose A U D IT screening test score is in

the range of 8-15. Even though they m ay

not be experiencing or causing harm ,

such patients are:

at risk of chronic health conditions

due to regular alcohol use in excess

of drinking guidelines; and/or

at risk of injury, violence, legal problem s,

poor w ork perform ance, or social prob-

lem s due to episodes of acute intoxica-

tion.

A ttention should be given to the num ber

of standard drinks consum ed per day or

per w eek to determ ine w hether low -risk

lim its are being exceeded. These drinking

lim its should take into account both the

typical quantity per w eek (A UDIT questions

1 and 2) as w ell as frequency of heavy

drinking (intoxication) episodes (A U D IT

question 3). In general, a brief interven-

tion using sim ple advice is appropriate forthose drinking above the w eekly low -risk

lim it, even if they are not experiencing

harm . M oreover, a patient w ho drinks

below that level, but w ho reports (ques-

tion 3) consum ing m ore than 60 gram s

of pure alcohol per occasion (4-6 drinks

in m any countries) once or m ore during

the past year, should receive advice to

avoid drinking to intoxication.

Giv ing Sim p le A dv ic et o R isk Z o n e I I D r i n k e r s

Based on clinical trials and practical expe-

rience from early intervention program s

in m any countries9, 15, 16, sim ple advice

using a patient education brochure is the

intervention of choice for Zone II drinkers.

O ne such brochure,A Guide to Low-Risk Drinking included in A ppendix A, is

adapted from the guide developed for

the W H O Project on Identification and

M anagem ent of Persons w ith H arm ful

A lcohol C onsum ption 15, 17. Box 4 pro-

vides step-by-step exam ples of how to

introduce the subject and w hat to say

about each panel in the “G uide to Low -

Risk D rinking.”

A fter establishing that the A U D IT score is

in the range appropriate for sim ple advice,

a statem ent should be m ade to prepare

the patient for the intervention. This tran-

sitional statem ent is best accom plished by

reference to screening test results con-

cerning the frequency, am ount, or pattern

of drinking and problem s experienced in

relation to drinking. A copy of the leafletis then show n to the patient. N ot only

does it contain all of the inform ation nec-

essary for the patient, it also provides

a com plete visual guide for the health

w orker’s spoken advice. By review ing

each panel in sequence w ith the patient,

a standard brief intervention can be deliv-

ered in a com plete, natural w ay that

requires a m inim um of training and prac-

tice on the part of the health w orker.

SIM PLE AD VICE FOR RISK ZON E II DRINKERS I1 7

Sim ple Advice fo rRisk Zone I I D r inke rs


19/53

G i v e F e e d b a ck ( Pa n e l 2 )

The health w orker should guide the

patient through the leaflet, section by

section, beginning w ith the D rinkers’

Pyram id, w hich is used to dem onstrate

that the person’s drinking falls into the

risky drinking category. (The percentages

show n in the D rinkers’Pyram id m ight

need to be adapted to the drinking pat-terns of different countries, as noted in

A ppendix A ).

The health w orker m ay adapt the script in

Box 4.

P ro v i d e I n f o r m a t i o n ( Pa n e l 3 )

The health care w orker should gently but

firm ly encourage the patient to takeim m ediate action to reduce the risks asso-

ciated w ith the current level of drinking.

U se the section “Effects of High-Risk

D rinking” to point out the specific risks of

continued drinking above recom m ended

guidelines.

E st a b l i sh a G o a l ( Pa n e l 4 )

The m ost im portant part of the sim ple

advice procedure is for the patient to

establish a goal to change drinking

behaviour. G uidelines are given in the

leaflet about choosing total abstinence or

low -risk drinking as a goal. In m any cul-

tures it is best for a health w orker to lead

patients to m ake their ow n decision. In

countries w here patients look to their

health care providers for definitive advice,a m ore prescriptive approach m ay be

appropriate.

In choosing a drinking goal, it is also

im portant to identify persons w ho should

be encouraged to abstain com pletely from

alcohol. The follow ing persons are not

appropriate for a low -risk drinking goal:

those w ith a prior history of alcohol

or drug dependence (as suggested by

previous treatm ent) or liver dam age;

persons w ith prior or current serious

m ental illness;

w om en w ho are pregnant;

patients w ith m edical conditions or w ho

are taking m edications that require total

abstinence.

Patients w ho are hesitant to establish a

goal, or w ho resist accepting the need

to do so, are likely to have m ore severe

problem s better dealt w ith by brief coun-

seling and related m otivational approach-

es as described in the next section (Brief

C ounseling for Risk Zone III D rinkers).

G i v e A d v i c e o n Li m i t s ( Pa n e l 5 )

M ost patients are likely to choose a low -

risk drinking goal. They then need to agree

to reduce their alcohol use to the “low -risk

drinking lim its” set forth in the leaflet.

These lim its are not the sam e in all coun-

tries. They vary depending on national pol-

icy, culture, and local drinking custom s.

They should also vary by gender, body

m ass, and the practice of drinking w ith

m eals, all of w hich can affect the m etab-

olism and health consequences of alcohol.

N evertheless, the follow ing guidelines areconsistent w ith epidem iological data18

indicating that the risk of a variety of



20/53


B o x 4

Sam ple Scr ip t o f a S imple Ad vice Session Using t he Guidet o Lo w - Ri sk D r i n k i n g

I n t r o d u c e t h e Su b j e c t w i t h a Tr a n si t i o n a l S t a t e m e n t

“I have looked over the results of the questionnaire you completed a few minutes

ago. If you remember, the questions asked about how much alcoho l you consume,

and whether you have experienced any prob lems in connection w ith your drinking .

From your answers it appears that you may be at risk of experiencing alcoho l-related

prob lems if you cont inue to drink at your current levels. I would like to take a few

minut es to talk w ith you about it.”

P re s e n t t h e G u i d e t o Lo w - R isk D r i n k i n g a n d Po i n t t o Pa n e l 2 :T h e D r i n k e r s’ P y r a m i d

“The best way to explain the health risks connected w ith your alcohol use is by fo l- low ing the illustrat ions in th is leaflet, which is called “A Guide to Low -Risk

Drinking.” Let’s take a look at it and then I will give you this copy to take home w ith

you. The first illustration, called the Drinkers’ Pyramid , describes four t ypes of

drinkers. While many people abstain f rom alcoho l completely, most people who

drink do so sensibly. This third area (High Risk Drinkers) represents drinkers whose

alcohol use is likely to cause problems. This top area represents peop le who are

sometimes called alcoho lics. These are peop le whose drink ing has led to depen-

dence and severe prob lems. Your responses to the questionnaire indicate that you

fall into the High Risk category. Your level of drinking presents risks to your health

and possibly other aspects of your life.”

Sh o w Pa n e l 3 a n d P r o v i d e I n f o r m a t i o n o n t h e E f f e c t s o f H i g h - R i skD r i n k i n g

“This picture show s the kinds of health prob lems that are caused by high -risk drin-

king . Have you ever experienced any of these problems yourself? The best w ay to

avoid these problems is to cut dow n on the frequency and quant ity of your drinking

so t hat you reduce your risk, or abstain ent irely from alcoho l.”


21/53


B o x 4 ( co n t i n u e d )

Po i n t t o Pa n e l 4 a n d D i scu ss t h e N e e d t o S t o p D r i n k i n g o r C u t D o w n

“It is import ant fo r you to cut down on your drinking or stop entirely for awhile.

Many people find it possible to make changes in their drinking. Are you w illing to

try? Ask yourself whether you have had any signs of alcoho l dependence like feeling

nauseous or shaky in the morn ing, or if you can drink very large amount s of alcoho l

w ithout appearing to be drunk. If th is is the case, you shou ld consider stopping

entirely. If you do not drink excessively most o f t he time, and do not feel that you

have lost cont rol over your drinking , then you should cut back.”

U s e Pa n e l 5 t o D i s cu s s S e n si b l e L i m i t s w i t h P a t i e n t s W h o C h o o set o D r i n k a t Lo w - R isk L e v e l s

“According to experts, you shou ld not have more than tw o drinks a day, and you

shou ld drink less if you tend to feel the eff ects of one or tw o drinks. To minimize

the risk of developing alcoho l dependence, there shou ld be at least tw o days a

week when you do not drink at all. You should always avoid drink ing to intoxication,

which can result from as litt le as tw o or three drinks on a single occasion. M oreover,

there are situat ions in which you shou ld never drink , such as the ones listed here.”

Po i n t t o Pa n e l 6 t o R e v i e w “W h a t ’s a S t a n d a r d D r i n k ”

“Finally, it is essential to understand how much alcoho l is cont ained in t he dif ferent

beverages you are drinking. Once you do this you can coun t your drinks and try to

stay w ith in low -risk lim its. This figure shows dif ferent types of alcoho lic beverages.

Did you know that one glass of w ine, one bot tle of beer, and one small shot of spir-

its all contain approximately the same amounts of alcoho l? If you th ink of each of these as a standard drink , then all you need to do is count the number of drinks you

have each day.”

C o n cl u d e W i t h En c o u r a g e m e n t

“Now that you have heard about the risks associated w ith drinking and t he sensible

limits, are there any questions? Many people find it reassuring to learn that they can

take action on their own to improve their health. I’m confident you can follow this

advice and reduce your drinking to low -risk limits. But if you find it dif ficult and

can’ t cut dow n, please call me or come back for another visit so we can talk about it again.”


22/53

health conditions and social consequences

is elevated above 20g per day. The sam e

am ounts taken on an individual occasion

are also likely to increase the risk of acci-

dents and injuries because of the psycho-

m otor im pairm ent caused by alcohol. The

guidelines are: no m ore than tw o standard

drinks per day. Both m en and w om en

should be advised to drink no m ore than

5 days per w eek. They should also berem inded of situations in w hich they

should not drink at all.

Ex p l a i n a “S t a n d a r d D r i n k” (Pane l6 )

If a patient chooses to reduce drinking,

and the health w orker has explained the

recom m ended lim its of low -risk drinking,

the idea of a standard drink should be

introduced by pointing to the illustration in

the leaflet. A ll of the drinks show n in the

leaflet should contain one standard drink.

P ro v i d e En co u r a g e m e n t

Rem em ber that hazardous drinkers are

not dependent on alcohol and can change

their drinking behaviour m ore easily. The

health care w orker should seek to m oti-

vate the patient by restating the need to

reduce risk and by encouraging the patient

to begin now . Since changing habits is

not easy, the health care w orker should

instil hope by rem inding patients that

occasional failures m ust be view ed as

opportunities to learn better w ays to m eet

the goal m ore consistently. For exam ple,

the health w orker m ight say,“It may not be easy to reduce your drinking to these

limits. If you go over the limit s on an

occasion, make an eff ort to learn why

you did and plan how not t o do it again.

If you always remember how important it

is to reduce your alcoho l-related risk, you

can do it.”

Cl in ica l A pp roa ch

The follow ing techniques contribute to the

effectiveness of delivering sim ple advice:

B e Em p a t h i c a n d N o n - j ud g m e n t a l

H ealth w orkers should recognize that

patients are often unaw are of the risks of

drinking and should not be blam ed for

their ignorance. Since hazardous drinking

is usually not a perm anent condition but a

pattern into w hich m any people occasion-

ally fall only for a period of tim e, a health

care provider should feel com fortable in

com m unicating acceptance of the person

w ithout condoning their current drinking

behaviour. Rem em ber that patients respond

best to sincere concern and supportive

advice to change. C ondem nation m ay

have the counterproductive effect of both

the advice and the giver being rejected.

B e A u t h o r i t a t i v e

H ealth w orkers have special authority

because of their know ledge and training.

Patients usually respect them for this exper-

tise. To take advantage of this authority, be

clear, objective, and personal w hen it com es

to stating that the patient is drinking above

set lim its. Patients recognize that true con-cern for their health requires that you pro-

vide authoritative advice to cut back or quit.



23/53

D e f l e c t D e n i a l

Som etim es patients are not ready to

change their drinking behaviour. Som e

patients m ay deny that they drink too

m uch and resist any suggestion that they

should cut dow n. To help patients w ho are

not yet ready to change, m ake sure that

you are speaking authoritatively w ithout

being confrontational. A void threateningor pejorative w ords like “alcoholic,” m oti-

vating the patient instead by giving infor-

m ation and expressing concern. If the

patient’s screening results have indicated

a high level of drinking or an alcohol-

related problem , use this inform ation to ask

them to explain the discrepancy betw een

w hat m edical authorities say and their

ow n view of the situation. You are then

in a position to suggest that things m aynot be as positive as they think.

F a c i l i t a t e

Since the intended outcom e of providing

sim ple advice is to facilitate the patient’s

behaviour change, it is essential that the

patient participate in the process. It is not

sufficient just to tell the patient w hat to

do. Rather, the m ost effective approach is

to engage the patient in a joint decision-

m aking process. This m eans asking about

reasons for drinking, and stressing the

personal benefits of low -risk drinking or

abstinence. O f critical im portance, the

patient should choose a low -risk drinking

goal or abstinence and agree at the con-

clusion of this process that he or she w ill

try to achieve it.


F o l l o w - u p

Periodic follow -up w ith each patient is

essential to sound m edical practice. Since

hazardous drinkers are not currently expe-

riencing harm , their follow -up m ay not

require urgent or expensive service.

H ow ever, follow -up should be scheduled

as appropriate for the perceived degree of

risk to assure that the patient is achievingsuccess in regard to the drinking goal.

If a patient is achieving success, further

encouragem ent should be offered. If not,

the health care w orker should consider

brief counseling or a referral for diagnostic

evaluation.


24/53

W h o i s A p p r o p r i a t e f o rBr ie f Counse l ing ?

An intervention using brief counseling

is generally appropriate for persons

w ho score on the A U D IT screening test in

the range of 16 –19. Patients receiving

such scores are likely to be harm ful drinkers

w ho are:

already experiencing physical and m ental

health problem s due to regular alcohol

use in excess of low -risk drinking guide-

lines; and/or

experiencing injuries, violence, legal

problem s, poor w ork perform ance, or

social problem s due to frequent intoxi-

cation.

W hile persons w ho score in this range on

the A U D IT w ill generally drink m ore than

those scoring less than 16, the key differ-

ence usually lies in responses to A U D IT

questions 9-10, w hich indicate signs of

harm . Indeed, som e patients in this cate-

gory m ay not drink m ore than those in

Zone II. If a patient indicates that an acci-

dent or injury has been experienced in the

past year, or that others have expressedconcern, brief counseling should be con-

sidered.

Brief counseling m ay also be appropriate

for hazardous drinkers w ho need to

abstain from alcohol perm anently or for a

period of tim e. This m ay be the case w ith

w om en w ho are pregnant or nursing and

w ith persons w ho are taking m edication

for w hich alcohol consum ption is con-

traindicated.

H ow Br ie f Counse l ingD i f f e r s f r o m Si m p l e A d v i ce

Brief counseling is a system atic, focused

process that relies on rapid assessm ent,

quick engagem ent of the patient, and

im m ediate im plem entation of change

strategies. It differs from sim ple advice in

that its goal is to provide patients w ithtools to change basic attitudes and han-

dle a variety of underlying problem s.

W hile brief counseling uses the sam e

basic elem ents of sim ple advice, its

expanded goal requires m ore content

and, thus, m ore tim e than sim ple advice.

In addition, health w orkers w ho engage

in such counseling w ould benefit from

training in em pathic listening and m otiva-

tional interview ing.

Like sim ple advice, the goal of brief coun-

seling is to reduce the risk of harm result-

ing from excessive drinking. Because the

patient m ay already be experiencing harm ,

how ever, there is an obligation to inform

the patient that this action is needed to

prevent alcohol-related m edical problem s.

Prov id ing Br ie f Counse l ing

There are four essential elem ents of brief

counseling:

G i v e B r i e f A d v i c e

A good w ay to begin brief counseling is

to follow the sam e procedures describedabove under sim ple advice, using the

G uide to Low -Risk D rinking as a w ay to

BRIEF COUNSELING FOR RISK ZONE II I DRINKERS I2 3

Brief Counsel ing f orRisk Zone I I I D r ink ers


25/53


26/53

BRIEF COUNSELING FOR RISK ZONE II I DRINKERS I2 5

B o x 5

Th e S t a g e s o f Ch a n g e a n dA sso ci a t e d B r ie f I n t e r v e n t i o n El e m e n t s20

S t a g e

Precontem plation

C ontem plation

Preparation

A ction

M aintenance

D e f i n i t i o n

The hazardous or harm ful

drinker is not considering

change in the near future,

and m ay not be aw are of the

actual or potential health

consequences of continued

drinking at this level

The drinker m ay be aw are of

alcohol-related conse-

quences but is am bivalent

about changing

The drinker has already

decided to change and plans

to take action

The drinker has begun to

cut dow n or stop drinking,

but change has not becom e

a perm anent feature

The drinker has achieved

m oderate drinking or absti-

nence on a relatively perm a-nent basis

B r i e f I n t e r v e n t i o n

El e m e n t s t o b eE m p h a s i z e d

Feedback about the results

of the screening, and

Information about the haz-

ards of drinking

Em phasize the benefits of

changing, give Information

about alcohol problem s, the

risksof delaying, and discuss

how to choose a Goal

D iscuss how to choose a

Goal, and give Advice and

Encouragement

Review Advice, give

Encouragement

G ive Encouragement


27/53

The booklet is entitled “How to Prevent

A lcohol-Related Problem s.” It provides

practical advice on how to achieve the

drinking lim its recom m ended in the G uide

to Low -Risk D rinking. It is based on sound

behaviour change strategies that have

been used to teach people to m odify their

drinking behaviour. Patients are asked to

develop a “Habit Breaking Plan” by read-

ing each section and recording inform a-tion that applies directly to their ow n situ-

ation. The first section asks the patient to

list the benefits that m ight be expected if

drinking is reduced. This is designed to

increase m otivation to change. The sec-

ond section asks for a list of high-risk sit-

uations that should be avoided because

they lead to excessive drinking. The third

section asks the patient to devise a set of

coping strategies to resist or avoid high-

risk situations. The final section solicits

ideas to cope w ith loneliness and bore-

dom . M ost patients can follow the self-

help booklet w ith a m inim um of explana-

tion and guidance, but som e patients

w ould benefit from having a health w ork-

er read through it w ith them so that the

H abit Breaking Plan can be com pleted

before they leave the office or clinic (see

Box 6). By com pleting the questions in

each section, the patient can leave the

brief counseling session w ith a clear goal

and a personalized plan to achieve it.

F o l l o w - u p

M aintenance strategies should be built

into the counseling plan from the begin-

ning. A practitioner of brief counselingshould continue to provide support, feed-

back, and assistance in setting, achieving,

and m aintaining realistic goals. This w ill

involve helping the patient identify relapse

triggers and situations that could endanger

continued progress. Since patients receiving

brief counseling are currently experiencing

alcohol-related harm , periodic m onitoring

as appropriate for the degree of risk dur-

ing and (for a tim e) after the counseling

sessions is essential. If the patient is m ak-

ing progress tow ard a goal or has achievedit, such m onitoring m ay be reduced to a

sem i-annual or annual visit. H ow ever, if the

patient continues for several m onths to

have difficulties reaching and m aintaining

the drinking goal, consideration should be

given to m oving the patient to the next

highest level of intervention, referral to

extended treatm ent if it is available. If such

specialized treatm ent if not available, reg-

ular m onitoring and continued counseling

m ay be necessary.


B o x 6

W o r k in g w i t hI l l it e r a t e Pa t i e n t s

Patients w ho are illiterate or have poor

reading ability w ill require special

help in brief counseling situations. It

is recom m ended that the health care

w orker review the self-help booklet

w ith the patient, assist in filling out

the plan, and (if the patient is w ill-

ing) suggest that the patient give the

m aterials to a friend or fam ily m em -

ber w ho m ight assist in rem indingthe patient of its contents.


28/53

P r e p a r a t i o n

Abrief intervention should not be used

as a substitute for care of patients

w ith a m oderate to high level of alcohol

dependence. It can, how ever, be used to

engage patients w ho need specialized

treatm ent. In preparation for using a brief

intervention to m otivate patients to accepta referral for diagnostic evaluation and

possible treatm ent, it w ill be necessary to

com pile inform ation about treatm ent

providers and, if possible, visit these pro-

gram s to establish personal contacts that

can be used to facilitate a referral.

A list of all alcohol treatm ent providers

should be m ade for the entire region,

including the services offered by each.Record nam es, phone num bers, and

addresses of the facilities, as w ell as other

inform ation that is relevant to your

patients. This m ight include outpatient,

day treatm ent, residential, and detoxifica-

tion program s as w ell as m ental health

facilities that can address the psychiatric

aspects of alcohol dependence. In addi-

tion, any halfw ay houses and group

hom es should be identified for thosepatients in need of living arrangem ents.

Finally, the list should include local m utual

help groups like A lcoholics A nonym ous,

as w ell as individual alcohol counselors in

the area. O ther com m unity services that

m ay be helpful to patients, such as voca-

tional rehabilitation and crisis services,

should also be identified.

Ref erra l for Zone IV Dr inkersw i th Probable Alcohol De pende nce

W h o R e q u i r e s Re f e r r a l t oD i a g n o si s a n d Tr e a t m e n t ?

Patients w ho score 20 or m ore on the

A U D IT screening test are likely to require

further diagnosis and specialized treat-

m ent for alcohol dependence. It should

be rem em bered, how ever, that the A U D IT

is not a diagnostic instrum ent, and it istherefore unw arranted to conclude (or

inform the patient) that alcohol depen-

dence has been form ally diagnosed.

In addition, certain persons w ho score

under 20 on the A U D IT, but w ho are not

appropriate for sim ple advice or brief

counseling, should be referred to specialty

care. These m ay include:

persons strongly suspected of having an

alcohol dependence syndrom e;

persons w ith a prior history of alcohol

or drug dependence (as suggested by

prior treatm ent) or liver dam age;

persons w ith prior or current serious

m ental illness;

persons w ho have failed to achievetheir goals despite extended brief coun-

seling.

P ro v i d i n g Re f e r r a l t oD i a g n o si s a n d Tr e a t m e n t

The goal of a referral should be to assure

that the patient contacts a specialist for

further diagnosis and, if required, treat-

m ent. W hile m ost patients know how

REFERRAL FOR RISK ZONE IV DRINKERS WITH PROBABLE ALCOHOL DEPENDENCE I2 7


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m uch they are drinking, m any are resis-

tant to taking im m ediate action to change.

The reasons for such resistance include:

not being aw are their drinking is

excessive;

not having m ade the connection

betw een drinking and problem s;

giving up the benefits of drinking; adm itting their condition to them selves

and others; and

not w anting to expend the tim e and

effort required by treatm ent.

The effectiveness of the referral process is

likely to depend upon a com bination of

the health care provider’s authority and the

degree to w hich the patient can resolvesuch resistance factors. A m odified form

of sim ple advice is useful for m aking a

referral, using feedback, advice, responsi-

bility, information, encouragement , and

follow-up .

F e e d b a c k

Reporting the results of the A U D IT screen-

ing test should m ake clear that:

the patient’s level of drinking far

exceeds safe lim its,

specific problem s related to drinking are

already present, and

there are signs of the possible presence

of alcohol dependence syndrom e.

It m ay be helpful to em phasize that suchdrinking is dangerous to the patient’s

ow n health, and potentially harm ful to

loved ones and others. A frank discussion

of w hether the patient has tried unsuc-

cessfully to cut back or quit m ay assist the

patient in understanding that help m ay

be required to change.

A d v i c e

The health care w orker should deliver the

clear m essage that this is a serious m edicalcondition and the patient should see a spe-

cialist for further diagnosis and possibly

treatm ent. The possible connection of

drinking to current m edical conditions should

be draw n, and the risk of future health

and social problem s should be discussed.

R e s p o n s i b i l i t y

It is im portant to urge the patientto dealw ith this condition by seeing the specialist

and follow ing recom m endations. If the

patient indicates such w illingness, infor-

m ation and encouragem ent should be

provided. If the patient is resistant, anoth-

er appointm ent m ay be needed to allow

the patient tim e to reflect on the deci-

sion.

I n f o r m a t i o n

Patients w ho have not previously sought

treatm ent for alcohol problem s m ay need

inform ation about w hat is involved. A fter

describing the health w orkers they w ill

m eet and the treatm ent they w ill receive,

patients are likely to be m ore receptive to

m aking a decision to enter treatm ent.



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E n c o u r a g e m e n t

Patients in this situation are likely to ben-

efit from w ords of assurance and encour-

agem ent. They should be told that treat-

m ent for alcohol dependence is generally

effective, but that considerable effort m ay

be needed on their part.

F o l l o w - u p

Follow ing alcohol treatm ent, patients

should be m onitored in the sam e w ay a

prim ary care provider m ight m onitor

patients being treated by a cardiologist or

orthopedist. This is particularly im portant

because the alcohol dependence syn-

drom e is likely to be chronic and recur-

ring. Periodic m onitoring and support

m ay help the patient resist relapse or tocontrol its course if it occurs.

REFERRAL FOR RISK ZONE IV DRINKERS WITH PROBABLE ALCOHOL DEPENDENCE I2 9


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A N o t e o n Ad a p t a t i o nan d Use

The brochure reproduced in this appen-

dix is based on the guide to low -risk

drinking that w as used to provide sim ple

advice to hazardous and harm ful drinkers

in the W H O Project on Identification

and M anagem ent of A lcohol-RelatedProblem s15, 17. The six panels can be

printed on tw o sides of a standard letter-

sized paper and folded into three parts

w ith the cover (Panel 1) on top.

The illustrations and guidelines provided

in this version should be review ed careful-

ly in term s of their appropriateness for

different cultural groups and prim ary care

populations. Each panel should be adapt-

ed to the circum stances of the screening

and brief intervention program m e con-

ducted in a given setting and country. The

percent figures in The D rinkers’Pyram id

of Panel 2 represent the proportion of the

population w ho are that type of drinker.

These figures should be based on local

survey data or estim ates of the propor-

tions of people representing each type ofdrinker. In som e countries, the propor-

tions of abstainers, low -risk drinkers, risky

drinkers, and persons w ith alcohol depen-

dence (alcoholics) m ay vary considerably.

G uidelines for the “Low -Risk Lim it” (Panel

5) can be m odified to fit national policy

and/or local circum stances. D ifferent lim its

for m ales, fem ales, and the elderly m ay

be cited. Sim ilarly, the list of activities

in w hich people should not drink at allshould be custom ized to fit culturally

specific conditions. Finally, Panel 6,

“W hat’s a Standard D rink?”, should be

m odified to show local alcoholic bever-

ages that are com parable in their

absolute alcohol content.

If the population w here the brochure is

distributed contains a large num ber of

persons w ho are illiterate or have lim ited

reading abilities, em phasis should be

given to the visual illustrations in theadaptation of the leaflet.

W h a t i s a S t a n d a r d D r i n k ?

In different countries, health educators

and researchers em ploy different defini-

tions of a standard unit or drink because

of differences in the typical serving sizes

in that country. For exam ple,

1 standard drink in C anada:

13.6 gram m es of pure alcohol

1 standard drink in the U K: 8 gram m es

1 standard drink in the U SA :

14 gram m es

1 standard drink in A ustralia or N ew

Zealand : 10 gram m es

1 standard drink in Japan:19.75 gram m es

In the A U D IT, Q uestions 2 and 3 assum e

that a standard drink equivalent is 10

gram s of alcohol. You m ay need to adjust

the num ber of drinks in the response cat-

egories for these questions in order to fit

the m ost com m on drink sizes and alcohol

strength in your country.


Appendix APat ient Educat ion Brochure


32/53


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A Guide t o Low -Risk Dr inking


Pane l 1


34/53

APPENDIX A I3 3

Pa n e l 2

T h e D r i n k e r s’ P y r a m i d

5%

20%

40%

35%

Probable Alcohol D ependence

H igh-Risk Drinkers

Low -Risk D rinkers

A bstainers

20+

A U D I T Sco r e s Typ e s o f D r i n k e r s

8 –19

1 –7

0


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Pane l 3

N um b, tingling toes.Painful nerves.

Im paired sensation

leading to falls.

Inflam m ation of the pancreas.

Vitam in deficiency. Bleeding.Severe inflam m ationof the stom ach. Vom iting.

D iarrhea. M alnutrition.

C ancer of throat and m outh .

Prem ature aging. D rinker's nose.

W eakness of heart m uscle.H eart failure. A nem ia.

Im paired blood clotting.Breast cancer.

In m en:Im paired sexual perform ance.

In w om en:Risk of giving birth to deform ed,

retarded babies or low birthw eight babies.

A ggressive,irrational behaviour.

A rgum ents. Violence.D epression. N ervousness.

Frequent colds. Reducedresistance to infection.Increased risk of pneum onia.

A lcohol dependence.M em ory loss.

U lcer.

Liver dam age.

Trem bling hands.Tingling fingers.N um bness. Painful nerves.

H igh-risk drinking m ay lead to social, legal, m edical, dom estic, job and financial

problem s. It m ay also cut your lifespan and lead to accidents and death from drunk-en driving.

E f f e c t s o f H i g h - R i sk D r i n k i n g


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Pa n e l 4

APPENDIX A I3 5

Sh o u l d I St o p D r i n k i n g o r Ju st Cu t D o w n ?

Yo u s h o u l d st o p d r i n k i n g i f :

You have tried to cut dow n before but have not been successful,

or

You suffer from m orning shakes during a heavy drinking period,

or

You have high blood pressure, you are pregnant, you have liver disease,

or

You are taking m edicine that reacts w ith alcohol.

Yo u s h o u l d t r y t o d r i n k a t l o w - r i sk l e v e l s i f :

D uring the last year you have been drinking at low -risk levels m ost of the tim e,

and

You do not suffer from early m orning shakes,

and

You w ould like to drink at low -risk levels.

N ote that you should choose low -risk drinking only if all three apply to you.


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Pa n e l 5

W h a t ’s a Low - Risk Lim i t ?

N o m ore than tw o standard drinks a day

D o not drink at least tw o days of the w eek

But remember. There are times when even one or two drinks can betoo much – for example:

W hen driving or operating m achinery.

W hen pregnant or breast feeding.

W hen taking certain m edications.

If you have certain m edical conditions.

If you cannot control your drinking.

A sk your health care provider for m ore inform ation.


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APPENDIX A I3 7

Pa n e l 6

1 can of ordinary beer

(e.g. 330 m l at 5% )

A glass of w ine or a sm all glass of sherry

(e.g. 140 m l at 12% or 90 m l at 18% )

A sm all glass of liqueur or aperitif

(e.g. 70 m l at 25% )

or

or

or

How Much is Too M uch? The most impor tant thing is the amount of pure alcohol in

a drink. These drinks, in normal measures, each contain roughly the same amount

of pure alcohol. Think o f each one as a standard drink .

W h a t ’s a S t a n d a r d D r i n k ?

1 st a n d a r d d r i n k =

A single shot of spirits (w hiskey, gin, vodka, etc.)

(e.g. 40 m l at 40% )


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A N o t e o n Ad a p t a t i o na nd U se

This booklet is based on “H ow to Prevent

A lcohol-Related Problem s: A Sensible

D rinking M anual” that w as developed by

R. H odgson to provide brief counseling in

the W H O Project on Identification and

M anagem ent of A lcohol-RelatedProblem s15, 17. The guidelines provided in

this generic version should be review ed

carefully in term s of their appropriateness

for different cultural groups and prim ary

care populations. Each section should be

adapted to the circum stances of the

screening and brief intervention pro-

gram m e conducted in a given setting and

country. For exam ple, the section on

“G ood Reasons for D rinking Less” pro-

vides a list of possible m otives people use

to convince them selves that they should

reduce their drinking. These m otives m ay

differ according to gender, culture, and

age. If the exam ples listed in the booklet

are not appropriate for your patients,

please change them to fit the needs of

the people you are interested in reaching.

If the population w here the booklet is dis-

tributed contains a large num ber of per-

sons w ho are illiterate or have lim ited

reading abilities, em phasis should be

given to the developm ent of visual illus-

trations and the booklet can be review ed

orally w ith the patient.


Appe ndix BSelf -Help Bookle t


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Wh o is Th is Boo k le t For ?

This booklet is not only for people w ho

have drinking problem s, it is also for

those people w ho are drinking sm aller

am ounts of alcohol but are drinking

enough to be at risk of developing future

health problem s.

The advice given in this booklet w ill help

both those people w ho have drinking

problem s and those w ho w ant to prevent

future problem s. The booklet provides:

A dvice on low -risk drinking lim its

G ood reasons for drinking at low -risk

level

A dvice on changing habits

The em phasis is on changing habits and

preventing future problem s.

C o n t e n t s

W hat is low -risk drinking?

How you can change your drinking habits?

G ood reasons for drinking less

H igh-risk situations

W hat to do w hen you are tem pted

People need people

W hat to do about boredom

H ow to stick to your plans

G uidelines for H elpers

C reating your habit-breaking plan

W h a t i s Lo w - Ri sk D r i n k i n g ?

Low -risk drinking involves lim iting alcohol

use to am ounts and patterns that are

unlikely to cause harm to oneself or oth-

ers. Scientific evidence indicates that the

risk of harm increases significantly w hen

people consum e m ore than tw o drinks

per day and m ore than five days perw eek. M oreover, even sm aller am ounts of

alcohol present risks in certain circum -

stances. Follow ing the sim ple rules below

can reduce the risk to your health and the

possibility you m ight hurt som eone else:

H ave no m ore than tw o drinks of alco-

hol per day

D rink no m ore than five days per w eek

D o not use any alcohol at tim es w hen

you:

D rive or operate m achinery

A re pregnant or breast feeding

A re taking m edications that react

w ith alcohol

H ave m edical conditions m ade w orse

by alcohol

C annot stop or control your drinking

A sk your health care w orker for m ore

inform ation about situations in w hich you

should lim it your drinking.

These low -risk drinking lim its are based

upon “standard” m easures of alcohol. It

is im portant for you to determ ine how

m uch alcohol is in each beverage youusually drink. M ost bottles and cans of

beer have about the sam e am ount of

APPENDIX B I3 9

How t o Prevent Alcohol-Relat ed Problem sA Self-help Booklet


41/53

alcohol as a glass of w ine or one shot of

distilled spirits. W hen you think about

how m uch you drink, be sure to count

standard drinks.

If you have been drinking above these lim -

its,you risk causing harm to yourself and

others. H aving three or m ore drinks on

one occasion creates risks of“accidents”

involving injuries, problem s in relation-ships and at w ork, and m edical problem s

such as hangovers, sleeplessness, and

stom ach problem s. D rinking m ore than

tw o drinks per day over extended periods

m ay cause cancer, liver disease, depres-

sion, and dependence on alcohol (alco-

holism ).

Fortunately, m ost people can stop or reduce

their drinking if they decide to do so and

w ork hard at changing their drinking habits.

The follow ing sections w ill tell you how .

H ow You Ca n Cha ng e YourD i n k i n g H a b i t s

W hen people successfully change their

habits they usually follow a sim ple plan.

This m anual w ill help you to produce a

sensible drinking plan. If possible, try to

get som ebody to help you. Perhaps a

friend or a relative, a health w orker or

m em ber of your religious com m unity

w ould be w illing and able to help you

w ork out a plan and stick to it. A sk that

person to read this booklet first.

The reason for getting somebody else

to help is simply that two heads are

better than one. Also, they will be

able to provide some support.

Another way of using this manual is

to get together with one or two other

people who also want to change their

drinking habits.

O f course, m any people change their

habits w ithout help from others. If you

are unable to get som ebody else to help,

then w ork out a plan by yourself.

First, you should ask yourself the follow ing

questions:

H ow w ill I benefit if I cut dow n on

m y drinking?

H ow w ill m y life im prove?

The next section w ill help you to answ er

these questions.

Good R e a s ons f o r D r ink ing

LessBased upon recent research on the effects

of alcohol, here is a list of benefits that

you can reasonably expect if you cut

dow n on your drinking. Read through

them and choose three that seem to be

the best reasons to you. C hoose the ones

that m ake you w ant to cut dow n.



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FO R W O M EN : There w ill be less chance

that I w ill dam age m y unborn child.

W hen you have chosen three good reasons

for cutting dow n on your drinking, m ake

a note of them in the spaces provided at

the end of this booklet under“C reating

Your H abit-Breaking Plan.”

N ow you should have a clearer picture inyour m ind of exactly w hat you expect to

happen if you continue to drink heavily

and a clearer picture of your future if you

stop drinking or drink w ithin low -risk lev-

els.

H igh- R isk Si t ua t ions

Your desire to drink heavily probably

changes according to your m oods, the

people you are w ith, and w hether or not

alcohol is easily available.

Think about the last tim e you drank too

m uch and try to w ork out w hat things

contributed to your drinking. W hat situa-

tions w ill m ake you w ant to drink heavily

in the future? For exam ple, here is oneperson's list:

Situations in w hich other people are

drinking and I am expected to drink.

Feeling bored and depressed, especially

on w eekends.

A fter a fam ily argum ent.

W hen drinking w ith m y friends.

W hen feeling lonely at hom e.

APPENDIX B I4 1

I f I d r i n k w i t h i n l o w - r i sk l i m i t s

I w ill live longer--probably betw een

five and ten years.

I w ill sleep better.

I w ill be happier.

I w ill save a lot of m oney.

M y relationships w ill im prove.

I w ill stay younger for longer.

I w ill achieve m ore in m y life.

There w ill be a greater chance that I

w illsurvive to a healthy old age w ithout

prem ature dam age to m y brain.

I w ill be better at m y job.

I w ill probably find it easier to stay slim ,

since alcoholic beverages contain m any

calories.

I w ill be less likely to feel depressed

and to com m it suicide (6 tim es less

likely).

I w ill be less likely to die of heart dis-

ease or cancer.

The possibility that I w ill die in a fire or

by drow ning w ill be greatly reduced.

O ther people w ill respect m e.

I w ill be less likely to get into trouble

w ith the police.

The possibility that I w ill die of liver

disease w ill be dram atically reduced

(12 tim es less likely).

It w ill be less likely that I w ill die in a

car accident (3 tim es less likely).

FO R M EN : M y sexual perform ance w ill

probably im prove.

FO R W O M EN: There w ill be less chance

that I w ill have an unplanned pregnancy.


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U se the follow ing list to help you identify

four situations in w hich you are m ost like-

ly to drink too m uch:

Parties Particular people

Festivals Tension

Fam ily Feeling lonely

Bars D inner parties

M ood Boredom

A fter W ork Sleeplessness

A rgum ents W eekends

Criticism After receiving pay

Feelings of failure W hen others are

drinking

W hen you have chosen the four danger-

ous situations or m oods that give you the

m ost trouble, w rite them dow n in the

pages provided at the end of this booklet

under “Creating Your H abit-Breaking Plan.”

The next task is to w ork out w ays of deal-

ing w ith these situations w ithout drinking

m ore than the recom m ended lim its.

W h a t t o D o w h e nYo u a r e Te m p t e d

In this section try to answ er the question:

H ow can I m ake sure that I'm not tem pted

to drink too m uch and, if I am tem pted,

w hat can I do to stop m yself?

This task is not easy but you m ay find it

easier if you get another person to help

and together you go through the follow -

ing steps:


C hoose one of your four high-risk situa-

tions.

Think of different w ays of avoiding or

coping w ith it.

Select tw o of these w ays to try out.

W rite them dow n in C reating Your

H abit-Breaking Plan at the end of this

booklet.

H ere is one m an's attem pt to w ork out a

w ay of coping w ith the tem ptation to

drink w ith friends after w ork.

H i g h - R i s k S i t u a t i o n

D rinking w ith friends after w ork.

W a y s o f Co p i n g W i t h o u t D r i n k i n g

t o o M u ch

G o hom e rather than drinking

Find another activity, e.g., exercise

Lim it the num ber of days drinking after

w ork w ith friends

H ave only tw o drinks w hen drinking

Sw itch to non-alcoholic beverages after

tw o drinks

C hange friends

W ork later

Tw o that I w ill try:

Lim it the num ber of days drinking

after w ork w ith friends

Sw itch to non-alcoholic beverages

after tw o drinks


44/53

N otice that som e of the ideas probably

w ould not w ork. This doesn't m atter

w hen trying to produce ideas. Just think

brief interview.pdf

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