Evidence-Based Reviews

Strategies to reduce alcohol use in problem drinkers

Current Psychiatry. 2011 November;10(11):30-42

A targeted approach can help reduce alcohol-related harm in at-risk patients

References

1. Schuckit MA, Anthenelli RM, Bucholz KK, et al. The time course of development of alcohol-related problems in men and women. J Stud Alcohol. 1995;56(2):218-225.

2. Wagner FA, Anthony JC. From first drug use to drug dependence; developmental periods of risk for dependence upon marijuana cocaine, and alcohol. Neuropsychopharmacology. 2002;26(4):479-488.

3. Rehm J, Room R, Graham K, et al. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction. 2003;98(9):1209-1228.

4. Dawson DA, Li TK, Grant BF. A prospective study of risk drinking: at risk for what? Drug Alcohol Depend. 2008;95(1-2):62-72.

5. Dinh-Zarr T, Goss C, Heitman E, et al. Interventions for preventing injuries in problem drinkers. Cochrane Database Syst Rev. 2004;(3):CD001857.-

6. Bradley KA, Donovan DM, Larson EB. How much is too much? Advising patients about safe levels of alcohol consumption. Arch Intern Med. 1993;153(24):2734-2740.

7. Babor TF, Higgins-Biddle JC. Brief intervention for hazardous and harmful drinking: a manual for use in primary care. World Health Organization. http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b.pdf. Accessed August 18 2011.

8. Kaner EF, 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.

9. Fleming M, Manwell LB. Brief intervention in primary care settings. A primary treatment method for at-risk problem, and dependent drinkers. Alcohol Res Health. 1999;23(2):128-137.

10. Whitlock EP, Polen MR, Green CA, et al. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140(7):557-568.

11. Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99(1-3):280-295.

12. Eberhard S, Nordström G, Höglund P, et al. Secondary prevention of hazardous alcohol consumption in psychiatric out-patients: a randomised controlled study. Soc Psychiatry Psychiatr Epidemiol. 2009;44(12):1013-1021.

13. Hulse GK, Tait RJ. Six-month outcomes associated with a brief alcohol intervention for adult in-patients with psychiatric disorders. Drug Alcohol Rev. 2002;21(2):105-112.

14. Hulse GK, Tait RJ. Five-year outcomes of a brief alcohol intervention for adult in-patients with psychiatric disorders. Addiction. 2003;98(8):1061-1068.

15. Milner KK, Barry KL, Blow FC, et al. Brief interventions for patients presenting to the Psychiatric Emergency Service (PES) with major mental illnesses and at-risk drinking. Community Ment Health J. 2010;46(2):149-155.

16. U.S. Department of Health and Human Services. Helping patients who drink too much: a clinician’s guide. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf. Updated 2005. Accessed August 18, 2011.

17. Fiellin DA, Reid MC, O’Connor PG. Outpatient management of patients with alcohol problems. Ann Intern Med. 2000;133(10):815-827.

18. Willenbring ML, Massey SH, Gardner MB. Helping patients who drink too much: an evidence-based guide for primary care clinicians. Am Fam Physician. 2009;80(1):44-50.

19. Batty GD, Lewars H, Emslie C, et al. Internationally recognized guidelines for ‘sensible’ alcohol consumption: is exceeding them actually detrimental to health and social circumstances? Evidence from a population-based cohort study. J Public Health (Oxf). 2009;31(3):360-365.

20. Barry KL, Milner K, Blow FC, et al. Screening psychiatric emergency department patients with major mental illnesses for at-risk drinking. Psychiatr Serv. 2006;57(7):1039-1042.

21. Satre D, Wolfe W, Eisendrath S, et al. Computerized screening for alcohol and drug use among adults seeking outpatient psychiatric services. Psychiatr Serv. 2008;59(4):441-444.

22. Goldstein BI, Velyvis VP, Parikh SV. The association between moderate alcohol use and illness severity in bipolar disorder: a preliminary report. J Clin Psychiatry. 2006;67(1):102-106.

23. Lagerberg TV, Andreassen OA, Ringen PA, et al. Excessive substance use in bipolar disorder is associated with impaired functioning rather than clinical characteristics, a descriptive study. BMC Psychiatry. 2010;10:9.-

24. Fleming MF, Balousek SL, Grossberg PM, et al. Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics. J Stud Alcohol Drugs. 2010;71(1):23-31.

25. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med. 1997;12(5):274-283.

26. Bertholet N, Daeppen JB, Wietlisbach V, et al. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med. 2005;165(9):986-995.

27. Cuijpers P, Riper H, Lemmers L. The effects on mortality of brief interventions for problem drinking: a meta-analysis. Addiction. 2004;99(7):839-845.

28. Grossberg P, Halperin A, Mackenzie S, et al. Inside the physician’s black bag: critical ingredients of brief alcohol interventions. Subst Abus. 2010;31(4):240-250.

29. D’Onofrio G, Pantalon MV, Degutis LC, et al. Development and implementation of an emergency practitioner-performed brief intervention for hazardous and harmful drinkers in the emergency department. Acad Emerg Med. 2005;12(3):249-256.

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Clinical Point

Most alcohol-related harm occurs in drinkers who do not meet criteria for an alcohol use disorder

Alcohol dependence is not an acute illness. Progression from alcohol use to dependence typically takes years, and alcohol dependence is a chronic illness with symptom severity that increases over time.1,2 As the level of alcohol intake increases, the probability of developing an alcohol use disorder, cirrhosis, seizures, cancer, hypertension, stroke, and injuries significantly increases.3,4 Most alcohol-related harm occurs in high-risk drinkers who do not meet DSM-IV-TR criteria for an alcohol use disorder.5,6

Clinicians therefore have an opportunity to intervene at early stages of alcohol use to help prevent progression to dependence and reduce harm. The concept of a continuum from low-to high-risk alcohol use is replacing the disease-oriented model that focuses on identifying and treating individuals who meet DSM-IV-TR criteria for alcohol use disorders (Figure 1).^4,7 Efforts to provide screening and intervention earlier in the disease course have:

mainly been carried out in the primary care setting
been aimed at nontreatment-seeking, nondependent individuals
led to recommendations for safe alcohol consumption limits.^8-10

One of the largest outreach efforts is a federally funded screening, brief intervention, referral to treatment (SBIRT) program established in 17 states that targets hospital emergency rooms, community health centers, and trauma centers.¹¹

Although research on the use of brief interventions for problem drinking in psychiatric settings is limited,^12-15 psychiatrists can employ these strategies, even during a brief medication management visit.

Figure 1: Recommended treatment based on type of alcohol use

NIAAA: National Institute on Alcohol Abuse and Alcoholism
Source: References 7,16

How much is too much?

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends men age <65 drink no more than 4 drinks/day and no more than 14 drinks/week and women of any age and men age ≥65 drink no more than 3 drinks/day and no more than 7 drinks/week.¹⁶ A standard drink is defined as 14 grams of absolute ethanol (12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits). Drinking above these levels is likely to result in harm and is defined as hazardous or at-risk use.^10,17,18 Harmful use is alcohol consumption that has resulted in adverse mental or physical effects.^10,17,18 We use “problem drinking” to describe both at-risk and harmful use as alcohol intake that exceeds NIAAA-recommended limits but does not meet DSM-IV-TR criteria for an alcohol use disorder.

In the United States, approximately 20% of the population exceeds NIAAA recommended alcohol intake guidelines without meeting criteria for an alcohol use disorder.¹⁸ Problem drinkers have an increased risk of developing an alcohol use disorder, nicotine dependence, liver disease, financial problems, marital disruptions, injuries, and driver’s license suspensions.^4-6,19

Problem drinking is common in psychiatric populations and may lead to difficulties beyond those experienced in the general population.^20,21 For example, problem drinking in individuals with bipolar disorder is associated with reduced medication compliance, greater functional impairment, and possibly more suicide attempts.^22,23 Even moderate alcohol use below the NIAAA-recommend levels may increase symptom severity in patients with bipolar disorder.^22,23

Interviewing techniques

Interventions to identify and treat problem drinkers have focused on the primary care setting because these physicians often are the only medical professionals problem drinkers encounter.^8-10 The style of counseling is based on motivational interviewing. Providers use therapeutic empathy, describe risk, deal with ambivalence and resistance, assess motivation to change, emphasize patient responsibility and self-efficacy, and provide a menu of specific strategies to reduce alcohol use. However, unlike standard motivational interviewing, in brief interventions, providers use clear, directive advice to reduce alcohol consumption in the context of the medical provider role. Brief interventions also draw on cognitive-behavioral therapy and general education strategies utilizing contracting, goal setting, and written materials such as self-help manuals.²⁴

Clinicians’ time demands have driven an effort to make interventions for problem drinkers efficient and time-limited. A single short intervention (5 to 15 minutes) can be effective, but 2 to 4 sessions of 5 to 15 minutes each seems to be more effective.^8,10 The emphasis is on increasing a patient’s insight and awareness of risk to prompt him or her to establish and manage a goal to reduce alcohol intake. As opposed to abstinence, which is commonly recommended for patients with alcohol use disorders, reducing intake typically is encouraged for problem drinkers.^9,10,16,18 For patients who use alcohol over the recommended limits and also meet criteria for an alcohol use disorder, clinicians can deliver a brief intervention, but should recommend abstinence from drinking and provide referral for further treatment.^9,10,16,18