By Thomas F. Babor and John C. Higgins-Biddle, World Health Organization, Department of Mental Health and Substance Dependence

Introduction

Brief interventions have become increasingly valuable in the management of individuals with alcohol-related problems.

Because brief interventions are low in cost and have proven to be effective across the spectrum of alcohol problems, health workers and policymakers have increasingly focused on them as tools to fill the gap between primary prevention efforts and more intensive treatment for persons with serious alcohol use disorders.

As described in this manual, brief interventions can serve as treatment for hazardous and harmful drinkers, and as a way to facilitate referral of more serious cases of alcohol dependence to specialized treatment.

This manual is written to help primary care health workers – physicians, nurses, community health workers, and others – to deal with persons whose alcohol consumption has become hazardous or harmful to their health.

Its aim is to link scientific research to clinical practice by describing how to conduct brief interventions for patients with alcohol use disorders and those at risk of developing them. The manual may also be useful for social service providers, people in the criminal justice system, mental health workers, and anyone else who may be called on to intervene with a person who has alcohol-related problems.

Whatever the context, brief interventions hold promise for addressing alcohol-related problems early in their development, thus reducing harm to patients and society. With the companion publication on the Alcohol Use Disorders Identification Test (AUDIT)1, these manuals describe a comprehensive approach to alcohol screening and Introduction brief intervention (SBI) that is designed to improve the health of populations and patient groups as well as individuals.

Once a systematic screening program is initiated, the SBI approach shows how health workers can use brief interventions to respond to three levels of risk: hazardous drinking, harmful drinking, and alcohol dependence. Brief interventions are not designed to treat persons with alcohol dependence, which generally requires greater expertise and more intensive clinical management.

The interested reader is referred to sources listed at the end of this manual for information about the identification and management of alcohol dependence2, 3.

Nevertheless, the SBI approach described in these pages specifies an important role for primary care practitioners in the identification and referral of persons with probable alcohol dependence to appropriate diagnostic evaluation and treatment. In addition, this manual describes how primary care health workers can use SBI as an efficient method of health promotion and disease prevention for the entire population of patients they see in their communities.

By taking a few minutes following screening to advise low-risk drinkers and abstainers about the risks of alcohol, primary care workers can have a positive impact on the attitudes and norms that sustain hazardous and harmful drinking in the community.  Concepts and Terms Anumber of terms and concepts are used here that may be new to primary health care health workers.

Fortunately, the terms are easy to understand and are sufficiently free of technical jargon to be used with patients. Many of these terms have now been incorporated into the nomenclature of the tenth revision of International Classification of Diseases (ICD-10)4. As ICD-10 becomes adopted into health care systems throughout the world, this manual will provide a practical way to use its terminology in everyday clinical practice.

In any discussion of alcohol-related problems, it is important to distinguish among “use,” “misuse,” and “dependence.” The word use refers to any ingestion of alcohol. We use the term low risk alcohol use to refer to drinking that is within legal and medical guidelines and is not likely to result in alcohol-related problems.

Alcohol misuse is a general term for any level of risk, ranging from hazardous drinking to alcohol dependence. Alcohol dependence syndrome is a cluster of cognitive, behavioural, and physiological symptoms. A diagnosis of dependence should only be made if three or more of the following have been experienced or exhibited at some time in the previous twelve months:  

* a strong desire or sense of compulsion to drink;  

* difficulties in controlling drinking in terms of onset, termination, or levels of use;  

* a physiological withdrawal state when alcohol use has ceased or been reduced, or use of alcohol to relieve or avoid withdrawal symptoms;  

* evidence of tolerance, such that increased doses of alcohol are required to achieve effects originally produced by lower doses;  

* progressive neglect of alternative pleasures or interests because of alcohol use;  

* continued use despite clear evidence of harmful consequences.

Because alcohol misuse can produce medical harm without the presence of dependence, ICD-10 introduced the term harmful use into the nomenclature. This category is concerned with medical or related types of harm, since the purpose of ICD is to classify diseases, injuries, and causes of death.

Harmful use is defined as a pattern of drinking that is already causing damage to health. The damage may be either physical (e.g., liver damage from chronic drinking) or mental (e.g., depressive episodes secondary to drinking).

Harmful patterns of use are often criticized by others and are sometimes associated with adverse social consequences of various kinds. However, the fact that a family or culture disapproves drinking is not by itself sufficient to justify a diagnosis of harmful use. A related concept not included in ICD-10, but nevertheless important to screening, is hazardous use.

Hazardous use is a pattern of alcohol consumption carrying with it a risk of harmful consequences to the drinker. These consequences may be damage to health, physical or mental, or they may include social consequences to the drinker or others.

In assessing the extent of that risk, the pattern of use, as well as other factors such as family history, should be taken into account. While it is important to diagnose a patient’s condition in terms of harmful use or dependence, it is equally important to understand the pattern of drinking that produces risk.

Some patients may drink in large quantities on particular occasions, but may not drink more than recommended amounts on a regular, weekly basis. Such drinking to the point of intoxication presents an acute form of risk involving injuries, violence, and loss of control affecting others as well as themselves.

Other patients may drink excessively on a regular basis and, having established an increased tolerance for alcohol, may not demonstrate marked impairment at high blood alcohol levels. Chronic excessive consumption presents risks of long-term medical conditions such as liver damage, certain cancers, and psychological disorders.

As will become obvious in the remainder of this manual, the purpose of making distinctions among patterns of drinking and types of risk is to match the health needs of different types of drinkers with the most appropriate interventions. Because of the heavy demands on busy health workers in primary care, interventions need to be brief.

Brief interventions are those practices that aim to identify a real or potential alcohol problem and motivate an individual to do something about it. In many cultures the labels or terms applied to excessive drinkers carry highly negative connotations.

The distinctions made here about types of misuse on a broad continuum are seldom reflected in popular concepts and terminology. To avoid arousing resistance and defensiveness, it is best wherever possible to describe patients’ alcohol use and drinking behaviours rather than to use personal labels.

Hence, discussion of hazardous drinking or alcohol dependence is preferable to labeling a patient as a binge drinker or an alcoholic.

This will allow patients to focus on changing their drinking behaviour without feeling defensive about the terms being applied to them.

Continued - Brief Intervention For Hazardous and Harmful Drinking