Conduct a Brief Intervention: Build Motivation and a Plan for Change

About half of your patients who screen positive for heavy drinking (see drinking level terms, below) will not have alcohol use disorder (AUD).^1,2 Nonetheless, a brief intervention is warranted for all those who drink heavily as well as those with health conditions that can worsen with any alcohol use. By taking a few moments to offer advice when needed, providers in both medical and mental health settings can help patients to decrease their alcohol intake and improve their health.^3–6

Many healthcare professionals may not feel confident, however, in their ability to intervene effectively with patients who need to cut back or quit drinking. Here, we provide background on alcohol brief intervention and a 7-step model for patient care. To help with follow-up, we provide links to other Core articles, resources, and an interactive, simplified sample workflow.

How long is a “brief” intervention?

Brief interventions are typically 5 to 15 minutes and are reinforced over future visits, usually in one to five sessions. They can be delivered during routine visits in primary care and other healthcare settings. A series of interventions appears to be more effective than one-time interventions, but even single interventions may have a positive impact on people’s motivation and health.⁴

Similarly, at times when delivering a full brief intervention isn’t feasible, you can lay the groundwork for change by making a simple statement connecting alcohol use with one or more of the patient’s health conditions, then following up at the next visit. (See Step 2 below, Give feedback and advice.)

What outcomes can we expect from brief interventions?

Systematic reviews of randomized trials with up to one year follow-up find the combination of screening and brief interventions for heavy drinking in adults to be effective in reducing self-reported alcohol use, compared to screening with minimal or no intervention thereafter. ^3,4,7 In addition, studies using “real-world” data from a large, diverse adult patient population show reduced heavy drinking over time following brief intervention.^8–10 Moreover, long-term follow-up studies of screening and brief intervention in adolescents indicate that physical and mental health benefits may continue into young adulthood.^11,12 Beyond providing health gains at individual and population levels, alcohol screening and brief intervention is one of the most cost-effective preventive services.¹³

For people with moderate to severe AUD, a brief intervention on its own is probably not sufficient.¹⁴ These patients can benefit from evidence-based behavioral healthcare, FDA-approved medications for AUD (that are easy to prescribe in primary care or by addiction specialist physicians), mutual support groups (such as Alcoholics Anonymous and Smart Recovery; see Resources, below), or a combination of these approaches. (See Core articles on treatment and referrals.)

What does a model brief intervention look like? Seven steps for patient care

The following steps will help you to advise and assist patients who drink too much. The steps incorporate motivational interviewing principles that may help patients to be more receptive to your advice and more motivated to change their drinking.¹⁵ These principles include expressing empathy, exploring the patient’s own reasons for reducing alcohol use, increasing the patient’s awareness of drinking consequences, and “rolling with resistance” by affirming patient autonomy and self-efficacy.¹⁶ (For an overview of motivational interviewing, as well as ways to adapt the brief intervention process for youth, see the Resources below.)

1. Ask permission: Start by setting the agenda to discuss alcohol use.
   • Request the patient’s permission to discuss alcohol use. Transition from screening to brief intervention by requesting permission to discuss your patient's use of alcohol. Use a question such as “There is one more issue that came up in your exam and lab results that I’d like to discuss with you, and that is your alcohol use. Are you okay discussing this?”
   • Reassure the patient that discussing alcohol use is a normal part of the exam just like discussing any other health behavior. Asking permission and providing this reassurance may help get patients “on board” with exploring their alcohol use, especially since many patients will have come to the visit for a different health problem.
2. Give feedback and advice: Discuss the patient’s current drinking, related risks, and goals.
   • Use the information learned during screening and assessment to give feedback about whether they’ve screened positive for heavy drinking. You can state simply that their current number of drinks per week is over recommended limits. With some patients, it may be more appropriate to express concern that any level of drinking is risky (See “When is having any alcohol too much?” in the Core article on the basics).
   • Link your concern about alcohol use with risks of specific physical and mental health conditions and emphasize the benefits of cutting back. (See Core articles on medical complications and mental health issues.) For example, reducing heavy drinking can help reduce symptoms of depression and anxiety,¹⁷ improve sleep,¹⁸ improve liver function,¹⁹ and lower cardiovascular risk.²⁰
   • For patients who drink heavily and do not have AUD, offer brief advice:
     • Recommend cutting back to the U.S. Dietary Guidelines levels or to quit if medically indicated.
     • If a patient hesitates to accept the goal you suggest, negotiate an individualized, initial goal such as cutting back to having no heavy drinking days, “zero behind the wheel,” or tracking how much they drink, with an ultimate goal of cutting back to the Dietary Guidelines levels. Follow up at the next visit.
   • For patients with AUD, offer “beefed up” brief advice:
     • Inform them that you believe they meet criteria for alcohol use disorder, that they can get better, and that you’re willing to help them. Follow up on the items below at the next visit.
     • Provide clear advice to quit drinking, but to cut down gradually because suddenly stopping can be life-threatening. Be cautious and consider the need for medically managed withdrawal. (See Core article on AUD.) If the patient is hesitant to abstain, then negotiate individualized drinking goals, with, for example, a starting goal of no heavy drinking days and an ultimate goal of abstaining or cutting back to the Dietary Guidelines levels.
     • Discuss evidence-based professional treatment as well as mutual support options. (See Core article on treatment.) Consider support in primary care with FDA-approved AUD medications, which are easy to prescribe, and regular follow ups. Your patients may be unaware of newer medications for AUD (acamprosate and naltrexone) and may find them more appealing than the older medication (disulfiram) that makes people feel sick if they drink alcohol.²¹ Consider referral to specialty behavioral healthcare, especially for patients with mental health comorbidities or more severe AUD. Advise patients to try different mutual support groups to find a good fit. (See Resources, below.)
     • If the patient is hesitant to accept a referral, discuss possible barriers. Inform patients that effective AUD treatment can be offered conveniently on an outpatient basis and via telehealth, which may help reduce stigma. (See Core articles on stigma and referral.) Follow up by phone as needed to promote effective linkage to specialty care.²²
   • Keep in mind that some patients should not drink at all. In addition to those with AUD, recommend abstinence for patients who:
     • Take certain over-the-counter or prescription medications.(See Core article on medication interactions.)
     • Have a medical condition caused or exacerbated by drinking, such as liver disease, bipolar disorder, abnormal heart rhythm, diabetes, hypertension, or chronic pain, among others. (See Core article on medical complications.)
     • Are younger than the legal drinking age of 21.
     • Are pregnant or trying to become pregnant.
     • Experience facial flushing and dizziness when drinking alcohol. Between 30% and 45% of people of East Asian heritage inherit gene variants responsible for an enzyme deficiency that causes these symptoms and amplifies the risk of alcohol-related cancers, particularly head and neck cancer and esophageal cancer, even at light drinking levels.²³ People of other races and ethnicities can carry similar variants.²⁴
3. Check in: Ask what patients think of this information.
   • Assess your patient’s understanding and readiness to change. Ask what they think of the information you’ve shared and gauge their understanding. Assess their readiness to change drinking habits. You might ask “How willing are you to consider making changes in your drinking?” and “what might you be willing to do?” These types of questions can help to create attainable goals.
   • Stay focused on the patient’s drinking and related risks. Many patients are surprised to learn that they are drinking at a level that puts them at risk for injuries and diseases. They may report that their friends drink the same amount or more. Stay focused on the patient’s own drinking levels, risks, and choice about making a change.
   • Dispel common misconceptions about alcohol. During your brief intervention, patients may share commonly held beliefs that, for example, being able to “hold your liquor” offers protection from alcohol problems, or that low levels of drinking, especially red wine, is healthy. Explain that people with a high tolerance for alcohol tend to drink more and have an increased risk of AUD.²⁵ Clarify that even low levels of drinking any alcoholic beverage have been linked with greater risks for several conditions, including high blood pressure,^26–30 arrythmias,^31–34 and stroke,^28,35,36 as well as cancers of the mouth and throat^37,38 and female breast.^37,39–43 (See Core article on medical complications.) Which risks you emphasize will depend on the patient.
4. Build motivation: Briefly explore reasons for making a change.
   • Help raise the patient’s awareness of the personal consequences of his or her drinking. Here are two approaches:
     • Use open-ended questions, for example, “What do you think might be some benefits of cutting back on your drinking?”
     • Use the patient’s AUD assessment, if applicable, as an opener. Based on the symptoms reported, you might say, for example, “You indicated that you’ve given up some activities that once were important to you in order to drink. Can you tell me more about that?” (See Core article on screening and assessment.)
   • Listen carefully for the patient’s own reasons for making a change.
     • Listen for concerns that may differ from yours. Although you might be most concerned about the impact of alcohol on your patients’ health, they might express more concern about other issues that could be strong motivators to cut down or quit, such as money and time spent drinking or alcohol-related conflicts with a partner.
     • If you hear signs that they may wish to cut back, ask them to say more. Your prompting can help them clarify their motivation and make the potential for change more tangible. Particularly towards the end of a brief intervention, patients talking about their own reasons for change and their commitment to change, called “change talk,” is associated with better alcohol use outcomes.⁴⁴
   • Listen for potential roadblocks to reducing drinking. When you advise cutting back or quitting, it’s not uncommon for patients to raise perceived benefits of drinking, which can present roadblocks to change. Understanding and showing empathy for a patient’s motivation to drink—whether, for example, to deal with stress, to have fun with friends, or for cultural reasons—can help when developing a plan to handle any roadblocks to reducing drinking.
   • Suggest general examples of benefits. If patients are unable to come up with any reasons for making a change, it may be helpful to suggest general examples of benefits, such as ways in which they would likely feel and function better, and ask if these resonate with the patient.
5. Offer support: Express empathy and encourage autonomy.
   • Maintain an empathic, nonjudgmental tone. An empathic and nonjudgmental tone helps build a rapport that can promote change. Expressing how difficult it can be to change a longstanding behavior such as drinking can help reduce the pressure patients might feel to succeed on the first attempt. This supportive approach is associated with alcohol use reduction among participants in intervention studies.⁴⁵
   • Support patient autonomy. It is important to support autonomy by respecting a patient’s ambivalence about making difficult behavior changes. Providers should avoid arguing with patients who express resistance to change and can remind them that they are in charge of their own decisions around alcohol use. In this way, providers can recognize a patient’s autonomy, while simultaneously offering clear recommendations and support.
   • Keep a line of communication open. Change takes time. If a patient is unwilling to try to reduce his or her drinking after you first express your concerns, keep a line of direct, nonjudgmental, constructive communication open. This could provide opportunities for brief interventions during subsequent visits.
6. Identify next steps: Work together to develop a plan for change.
   • Collaborate to help patients develop a “change plan” to solidify their goals and how they will reach them. NIAAA’s Rethinking Drinking website provides a helpful change plan template that allows patients to fill in the goal, timing, reasons for a change, strategies, people who can help, and ways to handle possible roadblocks. A change plan for a patient without AUD may focus largely on goals to cut back on drinking, whereas goals for those with AUD may also include taking an AUD medication, starting specialty care, or joining a mutual support group.
   • Discuss healthy ways to manage commonly encountered challenges when people cut back or quit drinking. See the Rethinking Drinking website for short self-help modules on building drink refusal skills and handling urges to drink and see the Core article on recovery for strategies to help patients cope with stress and negative moods.
   • Summarize what has been discussed and review immediate next steps that the patient is willing to take. Assess motivation as well as the confidence patients have in their ability to follow through on their agreed-upon steps.⁴⁶ For example, patients might feel strongly motivated to cut back yet lack confidence in their ability to do so because people close to them are heavy drinkers. In this case, further talk may be needed to help patients decide how to manage these and other possible roadblocks.
   • Prepare to follow up by letting your patient know that you will revisit these steps next time you talk.
7. Follow up: Continue the dialogue at the next visit.
   • Revisit the issue of alcohol. At subsequent appointments, revisit the issue of alcohol and what was agreed upon at the prior visit, even if the patient is not yet ready to reduce drinking. For example, if the patient agreed to track consumption or to consider pros and cons of cutting back, you can continue a dialogue and help to build motivation for change over time.
   • Explore challenges and discuss new strategies. Explore any challenges that may have arisen between appointments and acknowledge that change is difficult. Discuss new strategies that may be helpful in cutting back on alcohol use. Be encouraging and supportive of any efforts that patients have made in the direction of change and re-affirm your willingness to help them. Remind them that your only mission is to help them to improve their health and quality of life.

In closing, brief interventions may help patients reduce their unhealthy drinking. The first brief intervention may lead directly to change, or it may lay a foundation. Be persistent—several encounters may be needed before the patient becomes motivated and committed to change. An interactive, simplified sample workflow for clinical practice is linked below. Be sure to see the other Core articles on screening, treatment, referrals, and recovery.