This article originally appeared in the August 2004 Harvard Mental Health Letter and is provided courtesy of Harvard Health Publications.

Brief treatment for problem drinkers

According to national surveys, nearly a third of Americans consume more than the FDA-recommended two drinks a day for men and one for women. These people usually have stable jobs and families, and most of them do not qualify for a diagnosis of alcohol abuse or dependence. Even if some do, they rarely think of themselves as alcoholics or seek treatment for alcoholism. They reject the label, and they regard standard treatments, such as Alcoholics Anonymous and detoxification clinics, as irrelevant.

Yet this group is so large that it probably accounts for most of the problems caused by alcohol — including family conflict, accidents, injuries, and poor health. In the last 20 years, treatment professionals have begun to realize that reaching these incipient or potential alcohol abusers may be a good use of their time, training, and resources.

Professionals can take some hints from the many who do not need to be persuaded that they have a problem. An estimated 75% of alcohol abusers recover without professional treatment or 12-step groups. Some stop drinking entirely, and more cut back to a healthy level. They act because of social embarrassments, family arguments, legal problems, and health worries. Some change after a spiritual experience (President Bush is said to be one), and others suffer a disaster — losing a job, husband, or wife; being arrested or injured while driving drunk; or developing an alcohol-related illness. More often, incidents and symptoms accumulate gradually until the person cannot go on drinking in the accustomed way.

These people achieve abstinence or moderation, usually, by working out for themselves informal variants of all the standard treatments for alcoholism, from Alcoholics Anonymous to cognitive behavioral and motivational enhancement therapies. They may avoid persons, places, and situations that lead them to drink, rehearse what to do or say when invited to drink, repeatedly remind themselves why they have quit or cut down, steel themselves against relapse, and consult a higher power for support.

But studies show that even after recognizing the problem, many go for years before doing much about it, and often act decisively only when alcohol begins to affect their physical health. In one study, the interval between recognition and action was 10 years. Speeding up the process might be useful.

Screening
One way to start is to screen large numbers of people for alcohol problems. It can be done wherever health care is provided. The National Institute on Alcohol Abuse and Alcoholism sponsors a yearly National Alcohol Screening Day, with a program that includes a questionnaire, educational materials, and an opportunity to talk to a health care professional about alcohol. In 2003, 62,000 people were screened at 3,000 sites. A Workplace Alcohol Screening Campaign has also been conducted in collaboration with several professional and government organizations.

A widely used brief questionnaire goes by the acronym CAGE (see below). A person who answers yes to even one of these questions may have a problem that closer examination will reveal. It’s been found that the questionnaire identifies 60%–70% of alcohol abusers.

Even a person who answers “no” to all of the CAGE questions may be drinking heavily and at risk for dependence. A more detailed screening questionnaire, the 10-item Alcohol Use Disorders Identification Test (AUDIT) is available from the National Institute on Alcohol Abuse and Alcoholism and elsewhere. The questions cover the amount of drinking, binges, symptoms of addiction, and harm caused by alcohol.

Too often, people define “moderation” as the amount they themselves drink. If they learn how their alcohol consumption compares with the national average and FDA recommendations, it becomes more difficult to deny having a problem. Screening can also clarify what the FDA and professionals mean by “one drink”: 11/2 ounces of whiskey or vodka, a 5-ounce glass of wine, or a 12-ounce glass of beer.

CAGE (Cut down, Annoyed, Guilty, Eye-opener)
1. Have you ever felt that you should cut down?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Brief intervention
Whether you recognize a drinking problem yourself, are told about it by your family and friends, or learn about it through screening, clinical trials in many countries suggest that a little advice and encouragement may help you solve it. The source of advice could be a physician, an alcoholism counselor, or a lay person who is knowledgeable about alcohol. The helper can ask you how much you are drinking and let you know how it compares with the norm. He or she can provide a self-help manual or workbook, give a brief talk about the consequences of alcohol abuse, suggest that you keep records of your drinking and choose a goal (abstinence or cutting back), and if necessary refer you to professional treatment or a mutual aid group like AA or Rational Recovery.

In one study, for example, family doctors in Wisconsin treated several hundred patients who consumed an average of 20 drinks a week. They provided two counseling sessions lasting 15 minutes, two 5-minute telephone calls from an office nurse with scripted questions, and a workbook. A control group received only a booklet containing information about alcohol problems. After two years, patients who received counseling were drinking less and were less likely to be hospitalized or arrested because of alcohol use.

One approach that may be useful is motivational enhancement therapy. The therapist tries to help patients change by learning how ready they are. In the “precontemplation” stage, they have no immediate intention of changing. In the “contemplation” stage, they know that a problem exists and are thinking about it. In the “preparation” stage, they have already tried to change and intend to try again soon. In the “action” stage, they have changed and want to maintain their gains. The theory is that people must proceed one stage at a time, often regress temporarily, and need different advice and help at each stage.

One implication is that professionals should reach out more to people at the contemplation and precontemplation stages, where many problem drinkers languish too long. At the precontemplation stage, they need to have the issue raised; at the contemplation stage, they need to be given reasons for change and offered an opportunity to weigh the pros and cons; at the preparation and action stages, they need to make specific plans.

In one of the largest clinical trials ever conducted — the National Institute on Alcohol Abuse and Alcoholism’s Project MATCH — researchers found that four sessions of motivational enhancement therapy were as effective as 12 sessions of other therapies (preparation for Alcoholics Anonymous and cognitive behavioral therapy) in reducing alcohol consumption and alcohol abuse.

Resources
Computerized Drinker’s Check-up (DCU)
www.drinkerscheckup.com
This program provides confidential screening for alcohol problems, feedback, and suggestions for change. Registration costs $25.

National Alcohol Screening Day
http://www.mentalhealthscreening.org/alcohol.asp
800-253-7658

National Drug and Alcohol Treatment Referral Routing Service
800-662-HELP (4357)

National Institute on Alcohol Abuse and Alcoholism
www.niaaa.nih.gov
301-443-3860

The AUDIT questionnaire is available on this Web site. The NIAAA also provides a booklet, “Helping Patients with Alcohol Problems: A Health Practitioner’s Guide.”

Substance Abuse Treatment Facility Locator
findtreatment.samhsa.gov

Very brief treatment
For some alcohol abusers, even less may be enough. In one study, problem drinkers were helped by little more than responding to a public appeal. The advertisement was placed in newspapers, on television, on radio, and in leaflets and posters distributed in Toronto, Canada. It contained a telephone number along with the following message: “Thinking of a change in your drinking? Do you know that 75% of people change their drinking on their own? Call us for materials that can be completed at home.”

The average caller had a serious drinking problem — six drinks a day on more than three-quarters of all days. The researchers mailed callers the AUDIT questionnaire (sending it to a post office box to preserve anonymity). More than 800 people who returned the questionnaire were divided into two groups, both contacted only by mail. One received a motivational enhancement aid with individual feedback (comparing their drinking with population averages); the other group received only a pamphlet with general information about the effects of alcohol and suggestions on how to cut down. (These materials, including AUDIT, can be found at the Guided Self-Change Clinic, HYPERLINK "http://www.nova.edu/~gsc/" http://www.nova.edu/~gsc/).

A year later, according to their own reports, total alcohol consumption was down by nearly a third in both groups. Callers who were already at the contemplation or preparation stage and were confident of success had the greatest chance of improving. But individual feedback did not make a difference. Simply responding to the advertisement and questionnaire and reading the educational material was sufficient. The researchers point out that this kind of help costs little time or money, requires no travel, and imposes no stigmatizing label because everything is confidential. They think it could be especially attractive to people who recognize that they have a problem but reject standard treatments and do not see total abstinence as the solution.

Problems of evaluation
Despite the many reported successes of brief treatment, there is still some doubt about how well it stands up in the bulk of controlled studies. Some studies find that screening is effective, but others suggest that it costs too much given the amount of problem drinking uncovered. A meta-analysis of 22 studies of “bibliotherapy” — supplying printed materials to problem drinkers — suggested that it was as effective as more extensive and elaborate treatments. In contrast, a review of 12 studies found that more than one counseling session was needed to reduce problem drinking.

The effects of a brief intervention last for as long as a year or two, according to some studies, but that may be the limit. In a recent study, more than 500 problem drinkers were divided into four groups. Three groups received treatment (advice and educational materials with or without additional counseling), and the control group was put on a waiting list. Nine months later, those receiving any treatment were drinking less than the controls; all treatments were equally effective. But 10 years after that, there were no differences between the four groups. It’s hardly surprising that the effects of a few counseling sessions or educational pamphlets do not consistently last for as long as 10 years. But this result raises the question of what kinds of follow-up are needed to maintain improvement.

Obstacles and hopes
Practical obstacles to wider use of brief treatments remain. In a survey conducted several years ago by researchers at Columbia University, more than two-thirds of general practitioners said they did not regularly screen patients for alcohol problems. Forty percent said the issue was too difficult to discuss, more than a third said they did not have the time — and nearly 60% suspected patients would not tell the truth. Health maintenance organizations and insurers are still uncertain about the cost-effectiveness of screening. To avoid wasting resources, researchers need to learn more about which drinkers, with what kinds of problems, are most likely to make good use of short-term therapy. But no matter what that research reveals, the impact of screening and brief interventions has already permanently expanded the possibilities for alcohol abuse prevention and treatment.

References
Apodaca TR, et al. “A Meta-Analysis of the Effectiveness of Bibliotherapy for Alcohol Problems,” Journal of Clinical Psychiatry (March 2003): Vol. 59, No. 3, pp. 289–304.

Beich A, et al. “Screening and Brief Intervention Trials Targeting Excessive Drinkers in General Practice: Systematic Review and Meta-Analysis,” British Medical Journal (Sept. 6, 2003): Vol. 327, pp. 536–42.

Klingemann HK, et al. Promoting Self-Change from Problem Substance Use: Implications for Policy, Prevention, and Treatment. Kluwer, 2001.

Moyer A. “Brief Interventions for Alcohol Problems: A Meta-Analytic Review of Controlled Investigations in Treatment-Seeking and Non-Treatment-Seeking Populations,” Addiction(March 2002): Vol. 97, No. 3, pp. 279–92.

Sobell LC, et al. “Promoting Self-Change with Alcohol Abusers: A Community-Level Mail Intervention Based on Natural Recovery Studies,” Alcoholism: Clinical and Experimental Research (June 2002): Vol. 26, No. 6, pp. 936–48.

Whitlock EP, 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,” Annals of Internal Medicine (April 6, 2004): Vol. 140, No. 7, pp. 557–68.

Zarkin GA, et al. “The Costs of Screening and Brief Intervention for Risky Alcohol Use,” Journal of Studies on Alcohol (Nov. 2003): Vol. 64, No. 6, pp. 849–57.

For more references, please see www.health.harvard.edu/mentalextra.