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

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    Takeaways

    • With a brief intervention, you can help patients who drink too much to cut back or quit alcohol use as needed.
    • By providing non-judgmental feedback on your patients’ alcohol use and related risks, you can increase their motivation to make a healthy change.
    • By helping patients develop a "change plan," you can set goals with them and provide an opening to follow up at the next appointment and adjust the plan as needed.
    • For patients with alcohol use disorder (AUD), you can offer added support by linking them to specialty care, helping with a prescription of an FDA-approved medication, or both.

    The majority of your patients who screen positive for heavy drinking will not have alcohol use disorder (AUD).1,2 Nonetheless, all those who drink heavily warrant a brief intervention to reduce their risk of alcohol-related harm. If you take a few moments to talk with your patients after alcohol screening and offer them advice to cut back or quit when needed, you can help them to reduce their alcohol intake and have a positive impact on their health.3,4

    Many healthcare professionals may not feel confident, however, in their ability to intervene effectively with patients who drink too much. Here, we provide background on alcohol brief intervention and a 7-step model for patient care. We also link to other Core articles and resources to help with follow-up and offer a simplified sample workflow at the end of this article.

    A note on drinking level terms used in this Core article: The 2020-2025 U.S. Dietary Guidelines states that for adults who choose to drink alcohol, women should have 1 drink or less in a day and men should have 2 drinks or less in a day. These “low-level” amounts, which the U.S. Dietary Guidelines calls “drinking in moderation,” are not intended as an average but rather a daily limit. Heavy drinking has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

    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.3 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.

    What outcome can we expect from brief interventions?

    Systematic reviews of randomized trials with up to one year follow-up found 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.4,5 

    For people with moderate to severe AUD, a brief intervention on its own is probably not sufficient.6 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.7 The 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.8 (For an overview of motivational interviewing, as well as ways to adapt the brief intervention process for culturally diverse populations, 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 or other concerns you may have about their drinking at any level.
      • 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,9 improve sleep,10 improve liver function,11 lower cardiovascular risk,12 and lower mortality risk.13
      • 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 that goal, 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 have 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.14 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.15
      • Keep in mind that some patients should not drink at all. Recommend abstinence for patients who:
        • Take medications that interact with alcohol (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, and chronic pain, among others. (See Core article on medical complications.)
        • Are under 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 genes 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.16
    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 “Are you willing to consider making changes in your drinking?” and “what are you ready and 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 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. Inform them that people with a high tolerance for alcohol tend to drink more and have an increased risk of AUD.17 Additionally, the latest and most rigorous research casts doubt on previous studies that linked low drinking levels (of any alcohol beverage type) with protection from cardiovascular disease and indicates that any benefits have been overestimated.18
    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 screening and assessment article.)
      • 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.19
      • 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.20
      • 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 this visit, 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 drinking goals, 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. 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. A simplified sample workflow of the alcohol screening and brief intervention process is shown below and can be downloaded here [PDF – 211 KB]. Be sure to see the other Core articles on screening, treatment, referrals, and recovery.

    Resources

    Further Reading in the NIAAA Journal, Alcohol Research Current Reviews

    Resources to Share with Patients Related to this Article

    Alcohol SBIRT Resources Related to this Article

    Adapting alcohol SBIRT to culturally diverse populations

    Mutual Support Groups

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

    1. Dawson DA, Grant BF, Li TK. Quantifying the Risks Associated With Exceeding Recommended Drinking Limits. Alcohol Clin Exp Res. 2005;29(5):902-908. doi:https://doi.org/10.1097/01.ALC.0000164544.45746.A7
    2. Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2019:82. https://www.samhsa.gov/data/
    3. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012;157(9):645-654. doi:10.7326/0003-4819-157-9-201211060-00544
    4. Kaner EF, Beyer FR, Muirhead C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;2:CD004148. doi:10.1002/14651858.CD004148.pub4
    5. Kaner EFS, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: A systematic review. Drug Alcohol Rev. 2009;28(3):301-323. doi:https://doi.org/10.1111/j.1465-3362.2009.00071.x
    6. Saitz R. Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking. Drug Alcohol Rev. 2010;29(6):631-640. doi:10.1111/j.1465-3362.2010.00217.x
    7. DiClemente CC, Corno CM, Graydon MM, Wiprovnick AE, Knoblach DJ. Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychol Addict Behav. 2017;31(8):862-887. doi:10.1037/adb0000318
    8. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press; 2008:xiv, 210.
    9. Bahorik AL, Leibowitz A, Sterling SA, Travis A, Weisner C, Satre DD. The role of hazardous drinking reductions in predicting depression and anxiety symptom improvement among psychiatry patients: A longitudinal study. J Affect Disord. 2016;206:169-173. doi:10.1016/j.jad.2016.07.039
    10. Roehrs T, Roth T. Sleep, sleepiness, sleep disorders and alcohol use and abuse. Sleep Med Rev. 2001;5(4):287-297. doi:10.1053/smrv.2001.0162
    11. Osna NA, Donohue TM, Kharbanda KK. Alcoholic Liver Disease: Pathogenesis and Current Management. Alcohol Res Curr Rev. 2017;38(2):147-161.
    12. Piano MR. Alcohol’s Effects on the Cardiovascular System. Alcohol Res Curr Rev. 2017;38(2):219-241.
    13. Roerecke M, Gual A, Rehm J. Reduction of alcohol consumption and subsequent mortality in alcohol use disorders: systematic review and meta-analyses. J Clin Psychiatry. 2013;74(12):e1181-1189. doi:10.4088/JCP.13r08379
    14. Wallhed Finn S, Bakshi AS, Andréasson S. Alcohol consumption, dependence, and treatment barriers: perceptions among nontreatment seekers with alcohol dependence. Subst Use Misuse. 2014;49(6):762-769. doi:10.3109/10826084.2014.891616
    15. Glass JE, Andréasson S, Bradley KA, et al. Rethinking alcohol interventions in health care: a thematic meeting of the International Network on Brief Interventions for Alcohol & Other Drugs (INEBRIA). Addict Sci Clin Pract. 2017;12(1):14. doi:10.1186/s13722-017-0079-8
    16. Chang JS, Hsiao JR, Chen CH. ALDH2 polymorphism and alcohol-related cancers in Asians: a public health perspective. J Biomed Sci. 2017;24(1):19. doi:10.1186/s12929-017-0327-y
    17. Trim RS, Schuckit MA, Smith TL. The Relationships of the Level of Response to Alcohol and Additional Characteristics to Alcohol Use Disorders across Adulthood: A Discrete-Time Survival Analysis. Alcohol Clin Exp Res. 2009;33(9):1562. doi:10.1111/j.1530-0277.2009.00984.x
    18. Rehm J, Roerecke M. Cardiovascular effects of alcohol consumption. Trends Cardiovasc Med. 2017;27(8):534-538. doi:10.1016/j.tcm.2017.06.002
    19. Bertholet N, Faouzi M, Gmel G, Gaume J, Daeppen JB. Change talk sequence during brief motivational intervention, towards or away from drinking. Addict Abingdon Engl. 2010;105(12):2106-2112. doi:10.1111/j.1360-0443.2010.03081.x
    20. Moyers TB, Houck J, Rice SL, Longabaugh R, Miller WR. Therapist Empathy, Combined Behavioral Intervention and Alcohol Outcomes in the COMBINE Research Project. J Consult Clin Psychol. 2016;84(3):221-229. doi:10.1037/ccp0000074

     

    Earn CME/CE Credit

    We invite healthcare professionals including physicians, physician assistants, nurses, pharmacists, and psychologists to complete a post-test after reviewing this article to earn FREE continuing education (CME/CE) credit. This CME/CE credit opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA.

    CME/CE Activity — Conduct a Brief Intervention: Build Motivation and a Plan for Change

    Released on 5/6/2022
    Expires on 5/10/2024

    FREE

    This activity provides 0.75 CME/CE credits for physicians, physician assistants, nurses, pharmacists, and psychologists.
    Learn more about credit designations here.

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    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Describe the components of a brief intervention to encourage a patient to cut back or quit alcohol use as needed.
    • Describe strategies you can use to help patients build motivation for change.
    • Identify elements of non-judgmental feedback to help patients make a healthy change.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    External Writers

    Derek D. Satre, PhD
    Professor, Department of Psychiatry and
    Behavioral Sciences, University of California
    San Francisco;
    Adjunct Investigator, Kaiser Permanente
    Division of Research, Oakland, CA

    Constance M. Weisner, DrPH, MSW
    Research Scientist, Kaiser Permanente Division
    of Research, Oakland, CA
    Professor emeritus at the Department of
    Psychiatry, University of California,
    San Francisco, CA

    NIAAA Content Contributors

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    Katharine A. Bradley, MD, MPH
    Senior Investigator Kaiser Permanente,
    Washington Health Research Institute,
    Seattle, WA

    Randall Brown MD, PhD
    Professor, School of Medicine
    & Public Health,
    University of Wisconsin, Madison, WI

    Kathleen M. Carroll, PhD (Deceased)
    Professor of Psychiatry, Yale University School
    of Medicine, New Haven, CT

    Hector Colon-Rivera MD, MRO
    Medical Director of Asociacion
    Puertorriquenos En Marcha, Inc;
    Attending at University of Pittsburgh Medical
    Center, Philadelphia, PA

    Margot Trotter Davis, PhD
    Senior Research Associate at the Institute for
    Behavioral Health, Brandeis University Heller
    School for Social Policy, and Management,
    Waltham, MA

    Carlo C. DiClemente, PhD, ABPP
    Emeritus Professor of Psychology, University
    of Maryland Baltimore County, Baltimore, MD

    Constance M. Horgan, ScD
    Professor and Director, Institute for
    Behavioral Health, Heller School for Social
    Policy and Management,
    Brandeis University, Waltham, MA;
    Co-Director, Schneider Institutes for Health
    Policy and Research,
    Brandeis University, Waltham, MA

    Barbara S. McCrady, PhD
    Professor Emerita, Department of Psychology,
    University of New Mexico, Albuquerque, NM 

    William R. Miller, PhD
    Emeritus Distinguished Professor of
    Psychology and Psychiatry,
    University of New Mexico, Albuquerque, NM

    Constance M. Weisner, DrPH, MSW
    Research Scientist, Kaiser Permanente Division
    of Research, Oakland, CA
    Professor emeritus at the Department of
    Psychiatry, University of California,
    San Francisco, CA

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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