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18. Early Identification and Brief Intervention

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Summary:

  • Early identification of problem drinking, followed by brief interventions aimed at modifying behavior, can help minimize harm among individuals who are alcohol abusers but not dependent.
  • Brief interventions are well suited to implementation in a number of settings and for a range of populations who are at increased risk for problems.
  • Specific screening instruments can assist with the identification of problems and several have been adapted to meet the needs of particular populations, including young people or the elderly.
  • Early identification and brief interventions can be applied across cultures and are well suited for context where resources may be lacking or access to healthcare is limited.
  • For examples of interventions, see the online database Initiatives Reporting: Industry Actions to Reduce Harmful Drinking. 

Individuals with problematic drinking patterns fall into two major categories: those who can be diagnosed as “alcohol-dependent” and those who cannot, but whose drinking is still problematic and places them at risk for adverse health and social outcomes (see MODULE 17: Alcohol Dependence and Treatment).

For those whose drinking is problematic but who are not alcohol-dependent, early identification of problematic drinking can ensure that they receive interventions that can help reduce subsequent problems through modification of behaviors and drinking patterns [1]. Brief interventions are an example of targeted approaches that focus on specific groups rather than on population-wide prevention programs [2].

Early identification

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The implementation of brief intervention hinges upon the reliable identification of those in need of attention [3]. Several screening questionnaires have been developed to help detect problematic alcohol consumption. They include the Alcohol Use Disorders Identification Test (AUDIT) [4,5] and its variations—for example, Five-Shot questionnaire [6], AUDIT-C [7], Aus-AUDIT [8] —as well as the CAGE questionnaire [9]. Others include the Michigan Alcoholism Screening Test (MAST) [10, 11], the Early Detection of Alcohol Consumption test (EDAC) [12], the CRAFFT [13], RUFT-Cut [14], and RAPS-QF [15]. Each of these screening tools differs in its specificity and sensitivity [16], and some are more appropriate for certain target groups than for others, depending on gender, age, and other factors [17-21].

These screening instruments have a number of appealing features. They are relatively simple and easy to administer, either by trained professionals or the individuals themselves. The AUDIT, for example, one of the most commonly used screening instruments, can be applied both within and outside of professional settings and has been validated across a range of cultures [17, 22]. The test includes an assessment of frequency of drinking and outcomes of the individual’s drinking patterns [23]. Another advantage of developing succinct but effective screening tools is that they can help identify those in need of professional help without over-burdening primary care practitioners.

Alcohol abuse is often accompanied by several warning signs that relate to both an individual’s lifestyle and health issues. These include absenteeism from school or work or physical conditions related to blood pressure or liver enlargement [24]. These warning signs can be helpful in identifying individuals whose drinking patterns have placed them at increased risk. Follow-up using a screening instrument may be appropriate under these circumstances.

Brief intervention

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Once individuals with problematic drinking patterns have been identified, brief interventions can be applied. They are generally provided in the form of counseling and can help modify drinking patterns and reduce the potential for harm. The intervention process is generally administered in four or fewer short sessions with an end-goal that is agreed to by both the patient and the practitioner and may range from complete abstinence to modified drinking patterns.

The content of brief intervention settings varies depending on the severity of an individual’s problems. It includes several common elements known by their acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy [25]. The focus is on drinking patterns and includes advice on other medical problems (“feedback”). It should be noted that brief interventions can only be successful if the patient is willing to make a change (“responsibility”) and to take on board the advice offered by the practitioner on how to change drinking behavior (“advice”). The session will usually also include advice on how to make specific changes and develop skills that are likely to sustain these changes (“menu”). “Empathy” by the practitioner for the patient and a patient’s motivation to achieve the set goal of modifying drinking patterns (“self-efficacy”) are important factors for success of this approach.

Implementing brief interventions

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Brief intervention is effective primarily for individuals whose drinking patterns are problematic, but who are not alcohol-dependent [1, 26-29]. For drinkers who are alcohol-dependent, brief intervention may encourage them to enter and continue treatment [30-33]. Early identification and brief intervention lend themselves to a range of different sub-populations whose drinking patterns may be quite different and who require tailored approaches.

Age

Age of the patient is an important consideration in screening for alcohol problems and the subsequent administration of interventions. Adolescents and young adults constitute one of the key target groups among whom early identification and brief intervention can help reduce the risk for harm (see MODULE 11: Young People and Alcohol). Improved knowledge about drinking patterns and outcomes can increase the readiness of this group to reduce or otherwise modify consumption [34-37]. The relative simplicity of screening instruments and the ease with which they can be implemented have also allowed them to be communicated in ways that may be particularly appealing to young people. Electronic and web-based assessments, for example, have shown promise with students and young adults [38-40].

Young people from families with a history of substance abuse may be at particular risk for harmful drinking patterns. Early identification among these individuals relies on a modified version of the CAGE screening test [2]. The subsequent intervention can help them deal with alcohol abuse in their families and their own drinking behavior.

Alcohol abuse among older people is an area of growing importance, especially in countries with a rapidly increasing elderly population (see MODULE 23: Alcohol and the Elderly). The elderly are at increased risk for alcohol abuse due to loneliness, loss, social isolation, or failing health [41, 42]. However, alcohol abuse among the elderly remains a largely overlooked and under-served area [43]. Older individuals are less likely than younger people to seek assistance for problem drinking [41]. There is evidence, however, that brief interventions may be useful to address the needs of older people, both those living independently and those in long-term care facilities.

Assessment tools such as the CAGE questionnaire have been used for screening among this population, and geriatric versions of other tests—such as the MAST—have been adapted specifically with this target in mind [44-47].

Gender

There is evidence that although more men than women are affected by alcohol use disorders, women are more likely to seek help. At the same time, drinking problems in women are less likely to be identified at an early stage [48, 49]. As a result, early identification and brief intervention may be especially useful for women. Evidence suggests that women are responsive to brief interventions and likely to change their drinking behavior as a result of counseling [26, 48, 50-52].

However, there is also evidence that brief interventions may need to be further refined to address various gender-specific issues (see MODULE 9: Women and Alcohol). For example, mothers or pregnant women may need special attention to ensure that they are not deterred from seeking help by the lack of available child care, criminalization resulting in loss of child custody, and other obstacles [48, 53]. Conversely, women who abuse alcohol are less likely to seek prenatal care during pregnancy, lending a further dimension to the need for specially tailored interventions [53].

Other factors

Several additional factors play an important role in whether individuals with alcohol abuse disorders can be identified and provided with assistance. Many of those who are at increased risk also belong to socially marginalized groups or have low socioeconomic status and limited access to primary healthcare (see MODULE 8: “At-risk” Populations).

Included among these individuals are members of particular ethnic groups or indigenous populations who may not be part of the social mainstream. Also included are the homeless or impoverished populations. Access to regular medical primary care may be limited for many of these individuals. As a result, screening and brief intervention may be useful tools, provided that they are carefully tailored to their needs and are culturally sensitive and responsive [54, 55]. In order to reach these populations, brief interventions may be administered outside of the primary healthcare settings. For example, pharmacies may be used as venues for screening and interventions [56], and homeless shelters provide an opportunity to access hard-to-reach populations [57].

Implications for policy and prevention

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Early identification of problem drinkers and subsequent brief interventions have important implications for reducing the potential for harm. Brief interventions have been shown to reduce alcohol-related harm among problem drinkers [58, 59]. The ability to avoid negative health and social outcomes can contribute to reducing the social cost associated with alcohol abuse.

The flexibility of the approach lends itself to application without the need to involve professionals who specialize in treating addictions [60]. While general healthcare settings—such as physicians’ offices and general hospital admissions—are useful and desirable venues for assessment and treatment [27, 61-65], other settings are also appropriate for screening and interventions.

Emergency rooms offer a useful venue for administering early identification questionnaires and for applying brief intervention techniques [58]. Many of those who are admitted have already suffered harm as a result of their drinking and can be identified [15, 66, 67].

Other settings can also be used to meet the needs of communities where healthcare may be lacking or informal. For example, in some countries, pharmacists are the first point of contact with the primary healthcare sector for many people. Training pharmacists in screening and intervention techniques is, thus, an important resource [56]. Social workers also provide a valuable means of accessing at-risk populations, particularly those who may otherwise be harder to reach [68]. Finally, access to screening and intervention in the workplace offers a valuable approach to reaching a large number of individuals with problematic drinking patterns (see MODULE 22: Alcohol and the Workplace).

Successful implementation of the approach hinges on training personnel to administer the screening instruments, assess the results, and offer guidance to the patient for changing behavior and avoiding problems. It also requires that individuals with problematic patterns be aware that this resource is available to them. Follow-up on a patient’s progress is a crucial element in ensuring the success of this approach, regardless of the setting in which it is applied.

In recent years, web-based screening and brief intervention, also known as electronic screening and brief intervention (e-SBI), has emerged as another effective way of applying these techniques. E-SBI techniques are useful for a number of reasons: they can reach large numbers of people; perceived stigma is likely to be lower than face-to-face interventions, making patients more likely to seek counseling; and there is consistency in how they are delivered [69]. E-SBI has been shown to be effective in reducing problem drinking among heavy and harmful drinkers [69-73], and has also been shown to be cost effective [74]. Research has also shown that young people prefer web-based interventions to traditional face-to-face counseling [75], and e-SBI is feasible and effective in identifying problem drinkers and reducing harmful drinking among this population [76-80]. Therefore, e-SBI techniques may be particularly useful in addressing harmful consumption of alcohol among young people.

Conclusions

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For those individuals whose drinking is problematic but who are not alcohol-dependent, early identification of abusive patterns—followed by brief interventions—offers a simple, effective, and cost-efficient approach to treatment [81]. These methods may be particularly well suited to situations where resources are limited or access to health professionals trained in dealing with alcohol abuse is unavailable.

Brief intervention techniques and instruments have been developed and implemented in a range of settings. The approach is flexible and lends itself well to adaptation within various venues and for different populations. Cross-cultural validity is another important aspect of this measure, and there is evidence that instruments such as the AUDIT are applicable in a range of contexts. New approaches (e.g., the use of web-based screening) make this approach accessible to a broader population.

Given the effectiveness of early identification and brief intervention and how relatively simple these methods are to implement, this approach is a useful adjunct to primary healthcare and can be implemented through a range of channels. The ability to prevent alcohol problems at an early stage has important implications for healthcare and for the social costs associated with alcohol abuse.

The approach illustrates the effectiveness of targeted interventions that are aimed at specific populations with problematic drinking patterns rather than attempting to address the general population as a whole.

POLICY OPTIONS: Early Identification and Brief Intervention

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In developing policies and approaches, consideration of a number of key elements is required. While some may be necessary at a minimum and under most conditions, others may not be appropriate in all cases, or may be difficult to implement. The list below offers a menu of areas that need to be addressed, based on effective approaches that have been implemented elsewhere.

Screening and identification

Availability of screening tools to identify individuals at increased risk.

  • Specialized instruments, such as the AUDIT, MAST, and CAGE.

Availability of tailored Internet-based screening tools and assessments, with follow-up counseling where appropriate

Access to professionals trained to administer instruments and identify problematic drinking patterns. Professionals can include:

  • Health workers (nurses, doctors) in general practice and emergency rooms.
  • Reliance on other professionals where medical personnel is unavailable (e.g., health and social workers, pharmacists, educators).

Ensure a range of available screening tools appropriate for particular sub-populations, (e.g., young people, elderly, pregnant women).

Information

Education of professionals to administer assessment and offer intervention and follow-up.

  • Attention to individual needs, culture, gender, goals for treatment outcome (i.e., abstinence or changed patterns).

Education of patients to change behavior.

  • Information about drinking patterns and outcomes.
  • Skills for coping and avoiding relapse.

Provision of services

Services include assessment tools, counseling, and follow-up.

  • Integrated approach into general provision of health information and advice.
  • Where health services are unavailable, greater reliance on professionals such as social workers, pharmacists, and others.
  • Access to intervention through employers, educators, community.
  • Inclusion in workplace interventions, such as employee assistance programs (EAPs), information and awareness programs, and other initiatives.
  • Integration in online health services, such as university healthcare or workplace-assistance websites. 

Special considerations

Appropriateness of early identification and brief intervention where resources are scarce.

  • Availability of self-assessment instruments (including web-based approaches) for reaching broader populations.
  • Attention to cultural contexts and views about drinking patterns and problems.

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