Strategies to Reduce Alcohol Use in Problem Drinkers
When alcohol use increases, so does a person’s risk for cirrhosis, seizures, cancer, hypertension, stroke, and, most certainly, an alcohol use disorder. However, many people who experience these severe effects do not meet the Diagnostic and Statistical Manual IV criteria of dependence; therefore, identifying and targeting the full spectrum of low-risk to high-risk alcohol use rather than just those who meet dependence criteria has become the focus.1 Screenings and interventions are now carried out in primary care settings, emergency rooms, community health centers, trauma centers, and most recently, psychiatric settings. Goulding and Fleming report on methods psychiatrists may use to intervene with risky alcohol use in their article “Strategies to Reduce Alcohol Use in Problem Drinkers.”
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) had defined a recommended limit of alcohol consumption: men younger than 65 should consume no more than four drinks per day or 14 drinks per week and women of any age and men older than 65 should consume no more than three drinks per day or seven drinks per week. The NIAAA also defines a “drink” as 12 ounces of beer, five ounces of wine, or 1.5 ounces of distilled spirit. Drinking above the NIAAA’s recommended limit is defined as “hazardous” or “at-risk” use. Twenty percent of the country’s population are at-risk drinkers who do not meet the criteria of dependence set by the DSM-IV.6 Frequently, the psychiatric population falls into this category and yield problematic effects, such as reduced medicine compliance, an increase in suicide attempts, an increase in symptom severity, and an increase in functional impairments.
Usually, intervention strategies for problem drinkers have focused on primary care settings and have been developed as efficient and quick.4 The five to 15 minute interventions focus on educating the patient on risks associated with their drinking, as well as developing a goal to cut back on consumption. Abstinence is recommended for persons dependent, but it is not necessary for those who are not.6 Results have shown that the mini-interventions are effective in reducing a patient’s drinking at both six and 12-month follow-ups, by approximately four drinks per week.8 Also, the interventions have shown to reduce suicide attempts, domestic violence incidents, assaults, and even child abuse.2 Implementing such interventions into a psychiatric setting would not be difficult.
Goulding and Fleming recommend physicians and psychiatrists use an approach referred to as the “Five A’s of Intervention,” which are ask, advise, assess, assist, and arrange.4 The first “A”, ask, is useful when sparking a conversation with a patient regarding their alcohol use. Goulding and Fleming state that asking about a wide range of topics, such as nicotine, exercise, and other health-related issues, will help to seem routine and decrease the chances of a patient becoming defensive. If the patient reports using alcohol, the physician should follow up with a second question regarding how often the patient has exceeded the recommended amount of drinks per day in the past year. If the patient has exceeded the recommended amount more than once, Goulding and Fleming state the screening should then move to assess the patient’s weekly alcohol intake, perhaps by using a chart that specifies what specifically constitutes a “drink.” These questions will help a physician determine whether or not the patient is a problem drinker.
Goulding and Fleming recommend that the physician “advise,” or provide feedback to problem drinkers; however, it is important for them to keep an empathetic tone and non-confrontational manner.4 When possible, the physician should relate the drinking to different aspects of the patient’s life, such as health, family, financial, and social, and recommend that the patient change their habit.4 When doing so, the physician should always recommend the patient change, rather than command it, and also state they are willing to help the patient achieve the goal.4 Goulding and Fleming state the physician should then “assess” their patient’s willingness to change. Oftentimes, connecting the risky drinking to personal consequences will encourage the patient to agree to changes and set goals to reduce drinking amounts.4
After the goal is initiated, the physician may “assist” with designing an appropriate treatment plan. Discussing strategies such as pacing, switching between alcoholic and nonalcoholic beverages, and keeping a drinking diary, along with offering handouts, will aid patients in preparing themselves to reach their goal.4 Goulding and Fleming recommend the physician help the patient identify problem situations and offer tips on how to avoid or manage them, often with the support of a family member or a friend.4 For patients not willing to make changes, the physician should review the benefits of cutting back and the risks of continued drinking, as well as discussing any barriers the patient may face when making changes.4 Finally, Goulding and Fleming suggest the physician schedule a follow-up appointment with the patient, to check on progress made and obstacles encountered. Specifically, a follow-up phone call two weeks after the initial appointment followed by a one-month check-up is ideal.4
Goulding and Fleming state that problem drinking is not always properly addressed in psychiatric settings.4 A study conducted by Barnaby and colleagues examined 200 psychiatric patients, in which 49 percent reported problem drinking; however, only 27 percent had medical records reporting alcohol use. Screening tools, such as CAGE or AUDIT, are not routinely used in psychiatric settings, and Goulding and Fleming believe that the tools would be helpful in identifying problem drinkers.7 Milner and colleagues report brief interventions used within psychiatric settings led to decreased drinking by an average of seven drinks per week over a period of six months. Therefore, Goulding and Fleming offer the “Five A’s of Intervention” as a helpful tool that may be used by physicians and psychiatrists both to identify and intervene with patients who are problem drinkers.
 Dawson, D.A.; Li, T.K.; and Grant, B.F. (2008). A Prospective Study of Risk Drinking: At Risk for What? Drug Alcohol Depend 95(1, 2): 62-72.
 Dinh-Zarr, T.; Goss, C.; Heitman, E.; et al (2004). Interventions for Preventing Injuries in Problem Drinkers. Cochrane Database Syst. Rev.: CD001857.
 Madras, B.K.; Compton, W.M.; Avula, D.; et al (2009). Screening, Brief Interventions, Referral to Treatment (SBIRT) for Illicit Drug and Alcohol Use at Multiple Healthcare Sites: Comparison at Intake and Six-Months Later. Drug Alcohol Depend 99(1-3): 280-295.
 Goulding, E. and Fleming, M. (2011). Strategies to Reduce Alcohol Use in Problem Drinkers. Current Psychiatry 10(11): 30-33; 41-42.
 U.S. Department of Health and Human Services. Helping Patients Who Drink Too Much: A Clinician’s Guide. http://pubs.niaaa.nih.gov/publications/Practicioner/CliniciansGuide2005/guide.pdf. Updated 2005. Accessed January 24, 2012.
 Willenbring, M.L.; Massey, S.H.; and Gardner, M.B. (2009). Helping Patients Who Drink Too Much: An Evidence-Based Guide for Primary Care Clinicians. Am Fam Physician 80(1): 44-50.
 Satre, D.; Wolfe, W.; Eisendrath, S.; et al (2008). Computerized Screening for Alcohol and Drug Use Among Adults Seeking Outpatient Psychiatric Services. Psychiatr Serv 59(4): 441-444.
 Kaner, E.F.; Dickinson, H.O.; Beyer, F.; et al (2009). The Effectiveness of Brief Alcohol Interventions in Primary Care Settings: A Systematic Review. Drug Alcohol Rev. 28(3): 301-323.
 Barnaby, B.; Drummond, C.; McCloud, A.; et al (2003). Substance Misuse in Psychiatric Inpatients: Comparison of a Screening Questionnaire Survey with Case Notes. BMJ 327(7418): 783-784.
 Milner, K.K.; Barry, K.L.; Blow, F.C.; et al (2010). Brief Interventions for Patients Presenting to the Psychiatric Emergency Service (PES) with Major mental Illnesses and At-Risk Drinking. Community Ment Health J 46(2): 149-155.