BRIEF INTERVENTION - WHOapps.who.int/iris/bitstream/10665/67210/1/WHO_MSD_MSB_01.6b.pdf · World Health Organization BRIEF INTERVENTION For Hazardous and Harmful Drinking A Manual

World Health Organization

B R I E FI N T E R V E N T I O N

For Hazardous and Harmful DrinkingA Manual for Use in Primary Care

Thomas F. BaborJohn C. Higgins-Biddle

WHO/MSD/MSB/01.6bOriginal: EnglishDistribution: General

Department of Mental Health and Substance Dependence

Department of Mental Health and Substance Dependence

World Health Organization

B R I E FI N T E R V E N T I O N

For Hazardous and Harmful DrinkingA Manual for Use in Primary Care

Thomas F. BaborJohn C. Higgins-Biddle

WHO/MSD/MSB/01.6bOriginal: EnglishDistribution: General

2 I BRIEF INTERVENTION FOR HAZARDOUS AND HARMFUL DRINKING

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Brief interventions have proven to be effective and have become increasingly valuable in the managementof individuals with hazardous and harmful drinking, thereby filling the gap between primary preventionefforts and more intensive treatment for persons with serious alcohol use disorders. Brief interventions alsoprovide a valuable framework to facilitate referral of severe cases of alcohol dependence to specializedtreatment.

This manual is written to help primary care workers - physicians, nurses, community health workers, andothers – to deal with persons whose alcohol consumption has become hazardous or harmful to their health.Its aim is to link scientific research to clinical practice by describing how to conduct brief interventions forpatients with alcohol use disorders and those at risk of developing them. The manual may also be usefulfor social service providers, people in the criminal justice system, mental health workers, and anyone elsewho may be called on to intervene with a person who has alcohol-related problems.

This manual is designed to be used in conjunction with a companion document that describes how toscreen for alcohol-related problems in primary health care, entitled “The Alcohol Use DisordersIdentification Test: Guidelines for Use in Primary Care”. Together these manuals describe a comprehensiveapproach to alcohol screening and brief intervention in primary health care.

AAcckknnoowwlleeddggeemmeennttssThe Department of Mental Health and Substance Dependence of the World Health Organization gratefullyacknowledges the helpful comments and suggestions of the following individuals who reviewed themanuscript: Olaf Gjerlow Aasland, Maria Lucia Formigoni, Nick Heather, Hem Raj Pal and John B. Saunders.The revision and finalisation of this document was coordinated by Maristela Monteiro with technicalassistance from Vladimir Poznyak of the WHO Department of Mental Health and Substance Dependence,and Deborah Talamini, University of Connecticut. Financial support for this publication was provided bythe Ministry of Health and Welfare of Japan.

© World Health Organization 2001

This document is not a formal publication of the World Health Organization (WHO), and all rights arereserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced,and translated, in part or in whole but not for sale or for use in conjunction with commercial purposes.

Authors alone are responsible for views expressed in this document, which are not necessarily those ofthe World Health Organization.

TABLE OF CONTENTS I 3

Table of Contents

Introduction

Concepts and Terms

Roles and Responsibilities of Primary Health Care

SBI: A Risk Management and Case Finding Approach

Alcohol Education for Low-Risk Drinkers, Abstainers and Others

Simple Advice for Risk Zone II Drinkers

Brief Counselling for Risk Zone III Drinkers

Referral for Risk Zone IV Drinkers with Probable Alcohol Dependence

Appendix

A. Patient Education Brochure A Guide to Low-Risk Drinking

B. Self-Help Booklet

C. Training Resources

References

4

5

7

11

14

17

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27

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47

49

Brief interventions have become increas-ingly valuable in the management of

individuals with alcohol-related problems.Because brief interventions are low in costand have proven to be effective across thespectrum of alcohol problems, health work-ers and policymakers have increasinglyfocused on them as tools to fill the gapbetween primary prevention efforts andmore intensive treatment for persons withserious alcohol use disorders. As describedin this manual, brief interventions can serveas treatment for hazardous and harmfuldrinkers, and as a way to facilitate referralof more serious cases of alcohol depen-dence to specialized treatment.

This manual is written to help primary carehealth workers – physicians, nurses, com-munity health workers, and others – to dealwith persons whose alcohol consumptionhas become hazardous or harmful to theirhealth. Its aim is to link scientific researchto clinical practice by describing how toconduct brief interventions for patientswith alcohol use disorders and those at riskof developing them. The manual may alsobe useful for social service providers, peoplein the criminal justice system, mental healthworkers, and anyone else who may becalled on to intervene with a person whohas alcohol-related problems. Whatever thecontext, brief interventions hold promise foraddressing alcohol-related problems early intheir development, thus reducing harm topatients and society.

With the companion publication on theAlcohol Use Disorders Identification Test(AUDIT)1, these manuals describe a compre-hensive approach to alcohol screening and

Introduction

brief intervention (SBI) that is designed toimprove the health of populations andpatient groups as well as individuals. Oncea systematic screening program is initiated,the SBI approach shows how health work-ers can use brief interventions to respondto three levels of risk: hazardous drinking,harmful drinking, and alcohol dependence.

Brief interventions are not designed to treatpersons with alcohol dependence, whichgenerally requires greater expertise andmore intensive clinical management. Theinterested reader is referred to sources list-ed at the end of this manual for informa-tion about the identification and manage-ment of alcohol dependence2, 3.

Nevertheless, the SBI approach described inthese pages specifies an important role forprimary care practitioners in the identifica-tion and referral of persons with probablealcohol dependence to appropriate diag-nostic evaluation and treatment.

In addition, this manual describes how pri-mary care health workers can use SBI as anefficient method of health promotion anddisease prevention for the entire populationof patients they see in their communities.By taking a few minutes following screen-ing to advise low-risk drinkers and abstain-ers about the risks of alcohol, primary careworkers can have a positive impact on theattitudes and norms that sustain hazardousand harmful drinking in the community.


Anumber of terms and concepts areused here that may be new to primary

health care health workers. Fortunately,the terms are easy to understand and aresufficiently free of technical jargon to beused with patients. Many of these termshave now been incorporated into thenomenclature of the tenth revision ofInternational Classification of Diseases(ICD-10)4. As ICD-10 becomes adoptedinto health care systems throughout theworld, this manual will provide a practicalway to use its terminology in everydayclinical practice.

In any discussion of alcohol-related prob-lems, it is important to distinguish among“use,” “misuse,” and “dependence.” Theword use refers to any ingestion of alco-hol. We use the term low risk alcohol useto refer to drinking that is within legaland medical guidelines and is not likely toresult in alcohol-related problems. Alcoholmisuse is a general term for any level ofrisk, ranging from hazardous drinking toalcohol dependence.

Alcohol dependence syndrome is a clusterof cognitive, behavioural, and physiologi-cal symptoms. A diagnosis of dependenceshould only be made if three or more ofthe following have been experienced orexhibited at some time in the previoustwelve months:

■ a strong desire or sense of compulsionto drink;

■ difficulties in controlling drinking interms of onset, termination, or levels ofuse;

■ a physiological withdrawal state whenalcohol use has ceased or beenreduced, or use of alcohol to relieve oravoid withdrawal symptoms;

■ evidence of tolerance, such thatincreased doses of alcohol are requiredto achieve effects originally produced bylower doses;

■ progressive neglect of alternative plea-sures or interests because of alcoholuse;

■ continued use despite clear evidence ofharmful consequences.

Because alcohol misuse can produce med-ical harm without the presence of depen-dence, ICD-10 introduced the term harm-ful use into the nomenclature. Thiscategory is concerned with medical orrelated types of harm, since the purposeof ICD is to classify diseases, injuries, andcauses of death. Harmful use is defined asa pattern of drinking that is already caus-ing damage to health. The damage maybe either physical (e.g., liver damage fromchronic drinking) or mental (e.g., depres-sive episodes secondary to drinking).

Harmful patterns of use are often criti-cized by others and are sometimes associ-ated with adverse social consequences ofvarious kinds. However, the fact that afamily or culture disapproves drinking isnot by itself sufficient to justify a diagno-sis of harmful use.

A related concept not included in ICD-10,but nevertheless important to screening, ishazardous use. Hazardous use is a pattern

CONCEPT AND TERMS I 5

Concepts and Terms

of alcohol consumption carrying with it arisk of harmful consequences to the drinker.These consequences may be damage tohealth, physical or mental, or they mayinclude social consequences to the drinkeror others. In assessing the extent of thatrisk, the pattern of use, as well as otherfactors such as family history, should betaken into account.

While it is important to diagnose apatient’s condition in terms of harmfuluse or dependence, it is equally importantto understand the pattern of drinkingthat produces risk. Some patients maydrink in large quantities on particularoccasions, but may not drink more thanrecommended amounts on a regular,weekly basis. Such drinking to the pointof intoxication presents an acute form ofrisk involving injuries, violence, and loss ofcontrol affecting others as well as them-selves. Other patients may drink exces-sively on a regular basis and, havingestablished an increased tolerance foralcohol, may not demonstrate markedimpairment at high blood alcohol levels.Chronic excessive consumption presentsrisks of long-term medical conditions suchas liver damage, certain cancers, and psy-chological disorders. As will become obvi-ous in the remainder of this manual, thepurpose of making distinctions amongpatterns of drinking and types of risk is to match the health needs of differenttypes of drinkers with the most appropri-ate interventions. Because of the heavydemands on busy health workers in pri-mary care, interventions need to be brief.

Brief interventions are those practices thataim to identify a real or potential alcoholproblem and motivate an individual to dosomething about it.

In many cultures the labels or termsapplied to excessive drinkers carry highlynegative connotations. The distinctionsmade here about types of misuse on abroad continuum are seldom reflected inpopular concepts and terminology. Toavoid arousing resistance and defensive-ness, it is best wherever possible todescribe patients’ alcohol use and drink-ing behaviours rather than to use person-al labels. Hence, discussion of hazardousdrinking or alcohol dependence is prefer-able to labeling a patient as a bingedrinker or an alcoholic. This will allowpatients to focus on changing their drink-ing behaviour without feeling defensiveabout the terms being applied to them.


Primary care health workers are in aunique position to identify and intervene

with patients whose drinking is hazardousor harmful to their health5. They may alsoplay a critical role in leading patients withalcohol dependence to enter treatment.Patients have confidence in the expertiseof health workers and expect them to beinterested in the health effects of drink-ing. The information provided by healthworkers is often critical not only in themanagement of disease but also in itsprevention. Primary health care is the mainvehicle for the delivery of health servicesin many parts of the world, with most ofthe world’s population consulting a physi-cian or other health worker at least oncea year. Because patients trust the informa-tion they receive from health workers,advice about alcohol use is likely to betaken seriously when given in the contextof a medical or preventive health consul-tation. Moreover, the primary care settingis ideal for continuous monitoring andrepeated intervention.

Unfortunately, some primary care healthworkers are reluctant to screen and coun-sel patients in relation to alcohol use.Among the reasons most often cited arelack of time, inadequate training, fear ofantagonizing patients, the perceivedincompatibility of alcohol counseling withprimary health care, and the belief that“alcoholics” do not respond to interven-tions. Each of these reasons constitutes amisconception that is contradicted by evi-dence as well as logic.

Lack of Time

A common concern expressed by healthworkers is that Screening and BriefIntervention (SBI) will require too muchtime. Given the demands of a busyhealthcare practice, it is reasonable toargue that the health worker’s first duty is to attend to the patient’s immediateneeds, which are typically for acute care.But such an argument fails to give appro-priate weight to the importance of alcoholuse to the health of many patients andoverestimates the time required. Becausealcohol use is a leading contributor tomany health problems encountered in primary care, SBI can often be delivered in the course of routine clinical practicewithout requiring significantly more time.A brief self-report screening test can bedistributed with other forms patients areasked to complete in the waiting room,or the questions can be integrated into aroutine medical history interview. Eitherway, screening requires only 2-4 minutes.Scoring and interpretation of the screen-ing test takes less than a minute. Oncethe screening results are available, only asmall proportion (5%-20%) of patients inprimary care are likely to require a briefintervention. For those who screen posi-tive, the intervention for most patientsrequires less than five minutes. If briefcounseling is required, up to 15 minutesis recommended to review the self-helpbooklet described in this manual and todevelop a plan for monitoring or referral.

ROLES AND RESPONSIBILITIES OF PRIMARY HEALTH CARE I 7

Roles and Responsibilitiesof Primary Health Care

Inadequate TrainingMany health workers feel that their train-ing is not adequate to screen and counselpatients in relation to alcohol use. Whileit is true that professional education isoften inadequate where alcohol is con-cerned, there are now ample opportuni-ties for training in use of new screeningand intervention techniques. Not only istraining relatively simple and easy, it isalso possible to train one person in a busyclinic to take responsibility for alcoholscreening, thereby reducing the burdenon other members of the health careteam. This manual can also help in train-ing health workers. Other resources arelisted in Appendix C.

Fear of AntagonizingPatients over a SensitivePersonal Issue Another common misconception aboutSBI is that patients will become angry ifquestioned about their drinking, or theywill deny having problems and resist anyattempts to change their drinking behav-iour. While denial and resistance aresometimes encountered from personswith alcohol dependence, harmful andhazardous drinkers are rarely uncoopera-tive. On the contrary, the experiencegained from numerous research studiesand clinical programs indicates thatalmost all patients are cooperative, andmost are appreciative when health work-ers show an interest in the relationshipbetween alcohol and health. In general,

patients perceive alcohol screening andbrief counseling as part of the healthworker’s role, and rarely object when it isconducted according to the proceduresdescribed in this manual.

Alcohol is not a Matter thatNeeds to be Addressed inPrimary Health CareThis misconception is contradicted by amassive amount of evidence showinghow alcohol is implicated in a variety ofhealth-related problems6. These problemsnot only affect the health of the individ-ual, but also the health of families, com-munities, and populations. In general,there is a dose-response relationshipbetween alcohol consumption and a vari-ety of disease conditions, such as liver cir-rhosis and certain cancers (e.g., mouth,throat, and breast). Similarly, the morealcohol an individual consumes, thegreater the risk of injuries, automobilecrashes, workplace problems, domesticviolence, drowning, suicide, and a varietyof other social and legal problems. Aswith secondhand smoke, excessive drink-ing has secondary effects on the healthand wellbeing of persons in the drinker’simmediate social environment.

Unintentional injuries, increased familyhealth care costs, and psychiatric prob-lems are some of the unintended conse-quences of harmful drinking. Thus, if pri-mary health care involves the preventionand treatment of such common physicaland mental conditions, it must addresstheir causes in alcohol misuse.


“Alcoholics” do notRespond to Primary CareInterventions.

Health workers who confuse all forms ofexcessive drinking with alcohol depen-dence often voice this misconception.Alcohol misuse includes much more thanalcohol dependence. Alcohol dependenceaffects a small but significant proportionof the adult population in many countries(3%-5% in industrialized nations), buthazardous and harmful drinking generallyaffect a much larger portion of the popu-lation (15%-40%). The purpose of a sys-tematic program of SBI in primary caresettings is two-fold. It will identify andrefer persons with alcohol dependence atan early stage in their drinking career,thereby preventing further progression ofdependence. A second purpose is to iden-tify and help hazardous and harmfuldrinkers who may or may not develop analcohol dependence syndrome, butwhose risk of serious alcohol-related harmcan be reduced. Contrary to popular mis-conceptions, SBI is effective with bothpopulations.

Persons with alcohol dependence respondwell to formal treatment and to the kindsof community-based assistance providedby mutual help societies7, 8. But thesesame individuals often need to be con-vinced that they have a problem withrespect to alcohol and need encourage-ment to seek help. This is an importantresponsibility of primary care health work-ers, who are in an ideal position to usetheir expertise, knowledge, and respected

role as gatekeepers to refer alcoholdependent patients to the appropriatetype of care.

Contrary to the belief that alcohol-relatedproblems cannot be managed in primarycare, hazardous and harmful drinkersrespond well to primary care intervention(see Box 1). Unlike persons with alcoholdependence, who should be referred tospecialist care, hazardous and harmfuldrinkers should be given simple adviceand brief counseling, respectively. Thesebrief interventions have been shown innumerous clinical trials to reduce theoverall level of alcohol consumption,change harmful drinking patterns, preventfuture drinking problems, improve health,and reduce health care costs9, 10, 11, 12.

Primary care providers are experienced intreating patients with diabetes and hyper-tension, who require initial identificationthrough screening, counseling aboutbehavioural change, and on-going sup-port. This expertise will prove useful inproviding similar help to hazardous andharmful drinkers.

SummaryThe reluctance of primary care healthworkers to conduct alcohol screening andbrief intervention is often based onassumptions about the difficulty of thetask, the time required, the skills needed,and the response of the patient. Upon clos-er examination, most of these perceivedbarriers to SBI are either misconceptions

ROLES AND RESPONSIBILITIES OF PRIMARY HEALTH CARE I 9

or minor challenges that can be easilyovercome. Perhaps more difficult toaddress, however, is the health workers’own attitudes toward and personal use ofalcohol. Given the obligation to providethe best possible health care to patients,

implementing a trial programme of SBImay provide the best opportunity to con-vince skeptics that it is feasible, efficient,and effective.


Box 1

The Evidence for Brief InterventionDuring the past 20 years, there have been numerous randomized clinical trials of briefinterventions in a variety of health care settings. Studies have been conducted inAustralia, Bulgaria, Mexico, the United Kingdom, Norway, Sweden, the United States,and many other countries. Evidence for the effectiveness of brief interventions has beensummarized in several review articles, including the following:

■ In one of the earliest review articles, Bien, et al.9 considered 32 controlled studiesinvolving over 6,000 patients, finding that brief interventions were often as effectiveas more extensive treatments. “There is encouraging evidence that the course ofharmful alcohol use can be effectively altered by well-designed intervention strategieswhich are feasible within relatively brief-contact contexts such as primary health caresettings and employee assistance programs.”

■ Kahan, et al.10 reviewed 11 trials of brief intervention and concluded that, while fur-ther research on specific issues is required, the public health impact of brief interven-tions is potentially enormous. “Given the evidence for the effectiveness of brief inter-ventions and the minimal amount of time and effort they require, physicians areadvised to implement these strategies in their practice.”

■ Twelve randomized controlled trials were reviewed by Wilk, et al.11, who concluded thatdrinkers receiving a brief intervention were twice as likely to reduce their drinking over 6to 12 months than those who received no intervention. “Brief intervention is a low-cost,effective preventive measure for heavy drinkers in outpatient settings.”

■ Moyer, et al.12 reviewed studies comparing brief intervention both to untreated controlgroups and to more extended treatments. They found “further positive evidence” forthe effectiveness of brief intervention, especially among patients with less severeproblems. Cautioning that brief intervention should not substitute for specialist treat-ment, they suggested that they might well serve as an initial treatment for severelydependent patients seeking extended treatment.

The remaining parts of this manualdescribe a risk management and case

finding approach to deal with hazardousand harmful drinkers in primary healthcare settings. It is based on the assumptionthat screening and brief intervention foralcohol is likely to have positive benefitsfor patients who receive their health carefrom a particular clinic or provider. Thisapproach focuses first on the individualpatient, but also takes into account thepatient’s family and social networks in the community. By using SBI as a way to provide early identification of alcoholproblems as well as to educate all patients,the negative effects of alcohol will bereduced over time.

Screening is the first step in the SBI process.It provides a simple way to identify personswhose drinking may pose a risk to theirhealth, as well as those who are alreadyexperiencing alcohol-related problems,including dependence. (See the companionmanual, AUDIT, The Alcohol Use DisordersIdentification Test: Guidelines for Use inPrimary Care.) Screening has other bene-fits as well. It provides the health workerwith information to develop an interven-tion plan, and it provides patients withpersonal feedback that can be used tomotivate them to change their drinkingbehaviour.

To conduct screening systematically, it isrecommended that a standardized, vali-dated screening instrument be used. This manual recommends the Alcohol Use Disorders Identification Test (AUDIT),which was developed by the World HealthOrganization to identify persons with

hazardous and harmful alcohol consumptionas well as alcohol dependence13. Althoughother self-report instruments have beenfound to be useful, the AUDIT has theadvantages of being:

■ Short, easy to use, and flexible, yet pro-vides valuable information for feedbackto patients;

■ Consistent with ICD-10 definitions of harmful alcohol use and alcoholdependence;

■ Focused on recent alcohol use;

■ Validated in many countries and availablein many languages.

The AUDIT consists of ten questions. Thefirst three items measure the quantity andfrequency of regular and occasional alcoholuse. The next three questions ask aboutthe occurrence of possible dependencesymptoms, and the last four questionsinquire about recent and lifetime problemsassociated with alcohol use.

Once screening has been conducted, thenext step is to provide an appropriateintervention that meets the needs of eachpatient. Typically, alcohol screening hasbeen used primarily to find persons withalcohol dependence, who are then referredto specialized treatment. In recent years,however, advances in screening procedureshave made it possible to screen for riskfactors, such as hazardous drinking andharmful alcohol use. Using the AUDIT, theSBI approach described in this manualoffers a simple way to provide each patientwith an appropriate intervention, basedon the level of risk. The four levels of riskand corresponding AUDIT scores shown in

SBI : A RISK MANAGEMENT AND CASE FINDING APPROACH I 11

SBI : A Risk Managementand Case Finding Approach

Box 2 are presented as general guidelinesfor assigning risk levels based upon AUDITscores. They may serve as a basis for makingclinical judgments to tailor interventionsto the particular conditions of individualpatients. This approach is based upon thepremise that higher AUDIT scores aregenerally indicative of more severe levelsof risk. The cut-off points, however, arenot based on sufficient evidence to benormative for all groups or individuals.Clinical judgment must be used to identifysituations in which the total AUDIT scoremay not represent the full risk level, e.g.,

where relatively low drinking levels masksignificant harm or signs of dependence.Nevertheless, these guidelines can serveas a starting point for an appropriateintervention. If a patient is not successfulat the initial level of intervention, follow-up should yield a plan to step the patientup to the next level of intervention. Readersare encouraged to consult carefully thecompanion manual1 on the AUDIT and toconsider its recommendations for adaptingthe scoring to national policies, local set-tings, gender differences, and other issuesthat cannot be addressed here.


Box 2

Risk Level Intervention AUDIT Score*

Zone I Alcohol Education 0-7

Zone II Simple Advice 8-15

Zone III Simple Advice plus 16-19Brief Counselingand Continued Monitoring

Zone IV Referral to Specialist 20-40for Diagnostic Evaluation and Treatment

*The AUDIT cut-off score may vary slightly depending on the country’s drinking pat-terns, the alcohol content of standard drinks, and the nature of the screening pro-gram. Consult the AUDIT manual for details. Clinical judgment should be exercised inthe interpretation of screening test results to modify these guidelines, especially whenAUDIT scores are in the range of 15-20.

The first level, Risk Zone I, applies to themajority of patients in most countries.AUDIT scores below 8 generally indicatelow-risk drinking. Although no interventionis required, for many individuals alcoholeducation is appropriate for several reasons:it contributes to the general awareness ofalcohol risks in the community; it mayserve as a preventive measure; it could beeffective for patients who have minimizedthe extent of their drinking on the AUDITquestions; and it might remind patientswith past problems about the risks ofreturning to hazardous drinking.

The second level, Risk Zone II, is likely tobe encountered among a significant pro-portion of patients in many countries. Itconsists of alcohol use in excess of drink-ing guidelines. Although drinking guide-lines vary from country to country,epidemiological data suggest that therisks of alcohol-related problems increasesignificantly when consumption exceeds20g of pure alcohol per day, which is theequivalent of approximately two standarddrinks in many countries6. An AUDIT scorebetween 8 and 15 generally indicateshazardous drinking, but this zone mayalso include patients experiencing harmand dependence.

The third level, Risk Zone III, refers to apattern of alcohol consumption that isalready causing harm to the drinker, whomay also have symptoms of dependence.Patients in this zone may be managed by a combination of simple advice, briefcounseling, and continued monitoring.AUDIT scores in the range of 16-19 oftensuggest harmful drinking or dependence,

for which a more thorough approach toclinical management is recommended.

The fourth and highest risk level, RiskZone IV, is suggested by AUDIT scores inexcess of 20. These patients should be referredto a specialist (if available) for diagnosticevaluation and possible treatment foralcohol dependence. Health workersshould note, however, that dependencevaries along a continuum of severity andmight be clinically significant even at lowerAUDIT scores. In the following sections, theclinical management of patients scoring ineach of these zones is described in moredetail.

SBI: A RISK MANAGEMENT AND CASE FINDING APPROACH I 13

Patients who screen negative on theAUDIT screening test (i.e., Zone I),

whether they are low-risk drinkers orabstainers, may nevertheless benefit frominformation about alcohol consumption.Most people’s alcohol use varies overtime. Thus, a person who is drinkingmoderately now may increase consump-tion in the future. Moreover, alcoholindustry advertising and media storiesabout the benefits of alcohol consump-tion may lead some non-drinkers to drinkfor health reasons and others who drinkmoderately to consume more. Therefore,a few words or written information aboutthe risks of drinking may prevent hazardousor harmful alcohol use in the future.

Patients should also be praised for theircurrent low-risk practices and remindedthat, if they do drink, they should staywithin the recommended allowances.Information about what constitutes astandard drink is essential to understandingthose limits. It may take less than a minuteto communicate this information and toask if the patient has any questions. Thepatient education brochure in Appendix A can be used for this purpose.

Box 3 provides a sample script for primarycare providers to illustrate how to man-age patients whose screening test resultsare negative.

How to Deal with Patientswho are Concerned aboutFamily Members andFriends

When the issue of alcohol use is raisedduring a primary care visit, it is notunusual for patients to be interested inthis information as a means of eitherunderstanding or helping family membersor friends. According to Anderson5, pro-viding advice to concerned family andfriends is important for two reasons:

■ advice may help to reduce the stressthat is often experienced by people inthe excessive drinker’s immediate socialenvironment; and

■ these people can play a critical role inhelping to change the drinker’s behaviour.Primary care providers can do at leastthree things to help a relative or friendcope with an excessive drinker14:

Listen Sympathetically

The primary care provider can ask theconcerned friend or family member todescribe the drinking problem they areattempting to deal with and its effect onthem. It is important to determine theseverity of the drinking problem in questionaccording to the criteria described in thismanual for hazardous drinking, harmfuldrinking, and alcohol dependence syn-drome. This information should bereceived confidentially and any questionsor comments should be non-judgmental.


Alcohol Education for Low Risk Drinkers,Abstainers and Others

ALCOHOL EDUCATION I 15

Box 3

What to do with Patients whose Screening Test Resultsare Negative

Provide Feedback about the Results of the Screening Test

Example

“I have looked over the results of the questionnaire you completed a few minutesago. If you remember, the questions asked about how much alcohol you consume,and whether you have experienced any problems in connection with your drinking.From your answers it appears that you are at low risk of experiencing alcohol-relatedproblems if you continue to drink moderately (abstain).”

Educate Patients about Low-Risk Levels and the Hazards of Exceeding them

Example

“If you do drink, please do not consume more than two drinks per day, and alwaysmake sure that you avoid drinking at least two days of the week, even in smallamounts. It is often useful to pay attention to the number of ‘standard drinks’ youconsume, keeping in mind that one bottle of beer, one glass of wine, and one drinkof spirits generally contain about the same amounts of alcohol. People who exceedthese levels increase their chances of alcohol-related health problems like accidents,injuries, high blood pressure, liver disease, cancer, and heart disease.”

Congratulate Patients for their Adherence to the Guidelines

Example

“So keep up the good work and always try to keep your alcohol consumption belowor within the low-risk guidelines.”

Note

The Patient Education Brochure in Appendix A can be used to provide alcohol educationto low-risk drinkers, placing emphasis on the Drinkers’ Pyramid (Panel 2), the standarddrink illustration (Panel 6) and the low-risk drinking guidelines (Panel 5).

Provide Information

Information is a form of support.Depending on the severity of the prob-lem, copies of the low-risk drinkingbrochure in Appendix A can be providedas well as information about differentkinds of specialized treatment.

Encourage Support and JointProblem-Solving

Family and friends are often the mostimportant influence on a drinker’s decisionto take positive action. They should beencouraged to speak with the problemdrinker individually or as a group to expresstheir concern, suggest constructive action,and provide emotional support. Such inter-ventions should attempt to set a positivetone, without accusatory, negative state-ments or highly charged confrontation.


Who is Appropriate for Simple Advice?

Abrief intervention using simple adviceis generally appropriate for patients

whose AUDIT screening test score is inthe range of 8-15. Even though they maynot be experiencing or causing harm,such patients are:

■ at risk of chronic health conditions due to regular alcohol use in excess of drinking guidelines; and/or

■ at risk of injury, violence, legal problems,poor work performance, or social prob-lems due to episodes of acute intoxica-tion.

Attention should be given to the numberof standard drinks consumed per day orper week to determine whether low-risklimits are being exceeded. These drinkinglimits should take into account both thetypical quantity per week (AUDIT questions1 and 2) as well as frequency of heavydrinking (intoxication) episodes (AUDITquestion 3). In general, a brief interven-tion using simple advice is appropriate forthose drinking above the weekly low-risklimit, even if they are not experiencingharm. Moreover, a patient who drinksbelow that level, but who reports (ques-tion 3) consuming more than 60 grams of pure alcohol per occasion (4-6 drinks in many countries) once or more duringthe past year, should receive advice toavoid drinking to intoxication.

Giving Simple Advice to Risk Zone II Drinkers

Based on clinical trials and practical expe-rience from early intervention programs in many countries9, 15, 16, simple adviceusing a patient education brochure is theintervention of choice for Zone II drinkers.One such brochure, A Guide to Low-RiskDrinking included in Appendix A, isadapted from the guide developed forthe WHO Project on Identification andManagement of Persons with HarmfulAlcohol Consumption15, 17. Box 4 pro-vides step-by-step examples of how tointroduce the subject and what to sayabout each panel in the “Guide to Low-Risk Drinking.”

After establishing that the AUDIT score isin the range appropriate for simple advice,a statement should be made to preparethe patient for the intervention. This tran-sitional statement is best accomplished byreference to screening test results con-cerning the frequency, amount, or patternof drinking and problems experienced inrelation to drinking. A copy of the leafletis then shown to the patient. Not onlydoes it contain all of the information nec-essary for the patient, it also provides a complete visual guide for the healthworker’s spoken advice. By reviewingeach panel in sequence with the patient,a standard brief intervention can be deliv-ered in a complete, natural way thatrequires a minimum of training and prac-tice on the part of the health worker.

SIMPLE ADVICE FOR RISK ZONE II DRINKERS I 17

Simple Advice for Risk Zone II Drinkers

Give Feedback (Panel 2)

The health worker should guide thepatient through the leaflet, section bysection, beginning with the Drinkers’Pyramid, which is used to demonstratethat the person’s drinking falls into therisky drinking category. (The percentagesshown in the Drinkers’ Pyramid mightneed to be adapted to the drinking pat-terns of different countries, as noted inAppendix A).

The health worker may adapt the script inBox 4.

Provide Information (Panel 3)

The health care worker should gently butfirmly encourage the patient to takeimmediate action to reduce the risks asso-ciated with the current level of drinking.Use the section “Effects of High-RiskDrinking” to point out the specific risks ofcontinued drinking above recommendedguidelines.

Establish a Goal (Panel 4)

The most important part of the simpleadvice procedure is for the patient toestablish a goal to change drinkingbehaviour. Guidelines are given in theleaflet about choosing total abstinence orlow-risk drinking as a goal. In many cul-tures it is best for a health worker to leadpatients to make their own decision. Incountries where patients look to theirhealth care providers for definitive advice,a more prescriptive approach may beappropriate.

In choosing a drinking goal, it is alsoimportant to identify persons who shouldbe encouraged to abstain completely fromalcohol. The following persons are notappropriate for a low-risk drinking goal:

■ those with a prior history of alcohol or drug dependence (as suggested byprevious treatment) or liver damage;

■ persons with prior or current seriousmental illness;

■ women who are pregnant;

■ patients with medical conditions or whoare taking medications that require totalabstinence.

Patients who are hesitant to establish agoal, or who resist accepting the need to do so, are likely to have more severeproblems better dealt with by brief coun-seling and related motivational approach-es as described in the next section (BriefCounseling for Risk Zone III Drinkers).

Give Advice on Limits (Panel 5)

Most patients are likely to choose a low-risk drinking goal. They then need to agreeto reduce their alcohol use to the “low-riskdrinking limits” set forth in the leaflet.These limits are not the same in all coun-tries. They vary depending on national pol-icy, culture, and local drinking customs.They should also vary by gender, bodymass, and the practice of drinking withmeals, all of which can affect the metab-olism and health consequences of alcohol.Nevertheless, the following guidelines areconsistent with epidemiological data18

indicating that the risk of a variety of



Box 4

Sample Script of a Simple Advice Session Using the Guideto Low-Risk Drinking

Introduce the Subject with a Transitional Statement

“I have looked over the results of the questionnaire you completed a few minutesago. If you remember, the questions asked about how much alcohol you consume,and whether you have experienced any problems in connection with your drinking.From your answers it appears that you may be at risk of experiencing alcohol-relatedproblems if you continue to drink at your current levels. I would like to take a fewminutes to talk with you about it.”

Present the Guide to Low-Risk Drinking and Point to Panel 2 :The Drinkers’ Pyramid

“The best way to explain the health risks connected with your alcohol use is by fol-lowing the illustrations in this leaflet, which is called “A Guide to Low-RiskDrinking.” Let’s take a look at it and then I will give you this copy to take home withyou. The first illustration, called the Drinkers’ Pyramid, describes four types ofdrinkers. While many people abstain from alcohol completely, most people whodrink do so sensibly. This third area (High Risk Drinkers) represents drinkers whosealcohol use is likely to cause problems. This top area represents people who aresometimes called alcoholics. These are people whose drinking has led to depen-dence and severe problems. Your responses to the questionnaire indicate that youfall into the High Risk category. Your level of drinking presents risks to your healthand possibly other aspects of your life.”

Show Panel 3 and Provide Information on the Effects of High-RiskDrinking

“This picture shows the kinds of health problems that are caused by high-risk drin-king. Have you ever experienced any of these problems yourself? The best way toavoid these problems is to cut down on the frequency and quantity of your drinkingso that you reduce your risk, or abstain entirely from alcohol.”


Box 4 (continued)

Point to Panel 4 and Discuss the Need to Stop Drinking or Cut Down

“It is important for you to cut down on your drinking or stop entirely for awhile.Many people find it possible to make changes in their drinking. Are you willing totry? Ask yourself whether you have had any signs of alcohol dependence like feelingnauseous or shaky in the morning, or if you can drink very large amounts of alcoholwithout appearing to be drunk. If this is the case, you should consider stoppingentirely. If you do not drink excessively most of the time, and do not feel that youhave lost control over your drinking, then you should cut back.”

Use Panel 5 to Discuss Sensible Limits with Patients Who Choose to Drink at Low-Risk Levels

“According to experts, you should not have more than two drinks a day, and youshould drink less if you tend to feel the effects of one or two drinks. To minimizethe risk of developing alcohol dependence, there should be at least two days a week when you do not drink at all. You should always avoid drinking to intoxication,which can result from as little as two or three drinks on a single occasion. Moreover,there are situations in which you should never drink, such as the ones listed here.”

Point to Panel 6 to Review “What’s a Standard Drink”

“Finally, it is essential to understand how much alcohol is contained in the differentbeverages you are drinking. Once you do this you can count your drinks and try tostay within low-risk limits. This figure shows different types of alcoholic beverages.Did you know that one glass of wine, one bottle of beer, and one small shot of spir-its all contain approximately the same amounts of alcohol? If you think of each ofthese as a standard drink, then all you need to do is count the number of drinks youhave each day.”

Conclude With Encouragement

“Now that you have heard about the risks associated with drinking and the sensiblelimits, are there any questions? Many people find it reassuring to learn that they cantake action on their own to improve their health. I’m confident you can follow thisadvice and reduce your drinking to low-risk limits. But if you find it difficult andcan’t cut down, please call me or come back for another visit so we can talk aboutit again.”

health conditions and social consequencesis elevated above 20g per day. The sameamounts taken on an individual occasionare also likely to increase the risk of acci-dents and injuries because of the psycho-motor impairment caused by alcohol. Theguidelines are: no more than two standarddrinks per day. Both men and womenshould be advised to drink no more than5 days per week. They should also bereminded of situations in which theyshould not drink at all.

Explain a “Standard Drink” (Panel6)

If a patient chooses to reduce drinking,and the health worker has explained therecommended limits of low-risk drinking,the idea of a standard drink should beintroduced by pointing to the illustration inthe leaflet. All of the drinks shown in theleaflet should contain one standard drink.

Provide Encouragement

Remember that hazardous drinkers arenot dependent on alcohol and can changetheir drinking behaviour more easily. Thehealth care worker should seek to moti-vate the patient by restating the need toreduce risk and by encouraging the patientto begin now. Since changing habits isnot easy, the health care worker shouldinstil hope by reminding patients thatoccasional failures must be viewed asopportunities to learn better ways to meetthe goal more consistently. For example,the health worker might say, “It may notbe easy to reduce your drinking to theselimits. If you go over the limits on an

occasion, make an effort to learn whyyou did and plan how not to do it again.If you always remember how important itis to reduce your alcohol-related risk, youcan do it.”

Clinical Approach

The following techniques contribute to theeffectiveness of delivering simple advice:

Be Empathic and Non-judgmental

Health workers should recognize thatpatients are often unaware of the risks ofdrinking and should not be blamed fortheir ignorance. Since hazardous drinkingis usually not a permanent condition but apattern into which many people occasion-ally fall only for a period of time, a healthcare provider should feel comfortable incommunicating acceptance of the personwithout condoning their current drinkingbehaviour. Remember that patients respondbest to sincere concern and supportiveadvice to change. Condemnation mayhave the counterproductive effect of boththe advice and the giver being rejected.

Be Authoritative

Health workers have special authoritybecause of their knowledge and training.Patients usually respect them for this exper-tise. To take advantage of this authority, beclear, objective, and personal when it comesto stating that the patient is drinking aboveset limits. Patients recognize that true con-cern for their health requires that you pro-vide authoritative advice to cut back or quit.


Deflect Denial

Sometimes patients are not ready tochange their drinking behaviour. Somepatients may deny that they drink toomuch and resist any suggestion that theyshould cut down. To help patients who arenot yet ready to change, make sure thatyou are speaking authoritatively withoutbeing confrontational. Avoid threateningor pejorative words like “alcoholic,” moti-vating the patient instead by giving infor-mation and expressing concern. If thepatient’s screening results have indicateda high level of drinking or an alcohol-related problem, use this information to askthem to explain the discrepancy betweenwhat medical authorities say and theirown view of the situation. You are thenin a position to suggest that things maynot be as positive as they think.

Facilitate

Since the intended outcome of providingsimple advice is to facilitate the patient’sbehaviour change, it is essential that thepatient participate in the process. It is notsufficient just to tell the patient what todo. Rather, the most effective approach isto engage the patient in a joint decision-making process. This means asking aboutreasons for drinking, and stressing thepersonal benefits of low-risk drinking orabstinence. Of critical importance, thepatient should choose a low-risk drinkinggoal or abstinence and agree at the con-clusion of this process that he or she willtry to achieve it.


Follow-up

Periodic follow-up with each patient isessential to sound medical practice. Sincehazardous drinkers are not currently expe-riencing harm, their follow-up may notrequire urgent or expensive service.However, follow-up should be scheduledas appropriate for the perceived degree ofrisk to assure that the patient is achievingsuccess in regard to the drinking goal. If a patient is achieving success, furtherencouragement should be offered. If not,the health care worker should considerbrief counseling or a referral for diagnosticevaluation.

Who is Appropriate forBrief Counseling?

An intervention using brief counselingis generally appropriate for persons

who score on the AUDIT screening test inthe range of 16 – 19. Patients receivingsuch scores are likely to be harmful drinkerswho are:

■ already experiencing physical and mentalhealth problems due to regular alcoholuse in excess of low-risk drinking guide-lines; and/or

■ experiencing injuries, violence, legalproblems, poor work performance, orsocial problems due to frequent intoxi-cation.

While persons who score in this range onthe AUDIT will generally drink more thanthose scoring less than 16, the key differ-ence usually lies in responses to AUDITquestions 9-10, which indicate signs ofharm. Indeed, some patients in this cate-gory may not drink more than those inZone II. If a patient indicates that an acci-dent or injury has been experienced in thepast year, or that others have expressedconcern, brief counseling should be con-sidered.

Brief counseling may also be appropriatefor hazardous drinkers who need toabstain from alcohol permanently or for aperiod of time. This may be the case withwomen who are pregnant or nursing andwith persons who are taking medicationfor which alcohol consumption is con-traindicated.

How Brief CounselingDiffers from Simple Advice

Brief counseling is a systematic, focusedprocess that relies on rapid assessment,quick engagement of the patient, andimmediate implementation of changestrategies. It differs from simple advice inthat its goal is to provide patients withtools to change basic attitudes and han-dle a variety of underlying problems.While brief counseling uses the samebasic elements of simple advice, itsexpanded goal requires more contentand, thus, more time than simple advice.In addition, health workers who engagein such counseling would benefit fromtraining in empathic listening and motiva-tional interviewing.

Like simple advice, the goal of brief coun-seling is to reduce the risk of harm result-ing from excessive drinking. Because thepatient may already be experiencing harm,however, there is an obligation to informthe patient that this action is needed toprevent alcohol-related medical problems.

Providing Brief Counseling

There are four essential elements of briefcounseling:

Give Brief Advice

A good way to begin brief counseling isto follow the same procedures describedabove under simple advice, using theGuide to Low-Risk Drinking as a way to

BRIEF COUNSELING FOR RISK ZONE III DRINKERS I 23

Brief Counseling for Risk Zone III Drinkers

initiate a discussion about alcohol. In thiscase the patient is informed that screen-ing results indicate present harm withinthe High-Risk Drinking category, as shownin the Drinkers’ Pyramid (Panel 2). Thespecific harm(s) (both identified by theAUDIT and from the patient’s presentingsymptoms) should be itemized, and theseriousness of the situation should beemphasized by referring to the illustrationin Panel 3.

Assess and Tailor Advice to Stageof Change

Further assessment beyond initial screen-ing can be an important aid to brief coun-seling. Diagnostic assessment involves abroad analysis of the factors contributingto and maintaining a patient’s excessivedrinking, the severity of the problem, andthe consequences associated with it.Another type of assessment is the motiva-tional stage of the patient, which can varyfrom no interest in changing drinkingbehaviour (pre-contemplation) to actualinitiation of a drinking moderation plan(action stage).

The Stages of Change represent a processthat describes how people think about,initiate, and maintain a new pattern ofhealth behaviour. The five stages summa-rized in Box 5 are each matched with aspecific Brief Intervention element. One ofthe simplest ways to assess a patient’sreadiness to change their drinking is touse the “Readiness Ruler” recommendedby Miller19. Ask the patient to rate on ascale of 1 to 10, “How important is it foryou to change your drinking?” (with 1

being not important and 10 being veryimportant). Patients who score in the lowerend of the scale are pre-contemplators.Those who score in the middle range (4-6)are contemplators, and those scoring inthe higher range should be consideredready to take action.

It is helpful to begin counseling in a waythat meets the patient’s current motiva-tion level. For example, if the patient is atthe pre-contemplation stage, then theadvice session should focus more on feed-back in order to motivate the patient totake action. If the patient has been think-ing about taking action (contemplationstage), emphasis should be placed on thebenefits of doing so, the risks of delaying,and how to take the first steps. If thepatient is already prepared for takingaction, then the health worker shouldfocus more on setting goals and securinga commitment from the patient to cutdown on alcohol consumption. For mostpatients, the standard sequence of Feed-back, Information, Goal selection,Advice, and Encouragement should befollowed, with minor modifications dictat-ed by the current stage of change.

Provide Skills Training via the Self-Help Booklet

After assessing the patient’s readiness tochange drinking behaviour, the provisionof a self-help booklet is recommended.Appendix B contains a modified versionof the self-help manual used in the WHOProject on Identification and Managementof Alcohol-Related Problems15, 17.


BRIEF COUNSELING FOR RISK ZONE III DRINKERS I 25

Box 5

The Stages of Change and Associated Brief Intervention Elements20

Stage

Precontemplation

Contemplation

Preparation

Action

Maintenance

Definition

The hazardous or harmfuldrinker is not consideringchange in the near future,and may not be aware of theactual or potential healthconsequences of continueddrinking at this level

The drinker may be aware ofalcohol-related conse-quences but is ambivalentabout changing

The drinker has alreadydecided to change and plansto take action

The drinker has begun tocut down or stop drinking,but change has not becomea permanent feature

The drinker has achievedmoderate drinking or absti-nence on a relatively perma-nent basis

Brief InterventionElements to beEmphasized

Feedback about the resultsof the screening, andInformation about the haz-ards of drinking

Emphasize the benefits ofchanging, give Informationabout alcohol problems, therisks of delaying, and discusshow to choose a Goal

Discuss how to choose aGoal, and give Advice andEncouragement

Review Advice, giveEncouragement

Give Encouragement

The booklet is entitled “How to PreventAlcohol-Related Problems.” It providespractical advice on how to achieve thedrinking limits recommended in the Guideto Low-Risk Drinking. It is based on soundbehaviour change strategies that havebeen used to teach people to modify theirdrinking behaviour. Patients are asked todevelop a “Habit Breaking Plan” by read-ing each section and recording informa-tion that applies directly to their own situ-ation. The first section asks the patient tolist the benefits that might be expected ifdrinking is reduced. This is designed toincrease motivation to change. The sec-ond section asks for a list of high-risk sit-uations that should be avoided becausethey lead to excessive drinking. The thirdsection asks the patient to devise a set ofcoping strategies to resist or avoid high-risk situations. The final section solicitsideas to cope with loneliness and bore-dom. Most patients can follow the self-help booklet with a minimum of explana-tion and guidance, but some patientswould benefit from having a health work-er read through it with them so that theHabit Breaking Plan can be completedbefore they leave the office or clinic (seeBox 6). By completing the questions ineach section, the patient can leave thebrief counseling session with a clear goaland a personalized plan to achieve it.

Follow-up

Maintenance strategies should be builtinto the counseling plan from the begin-ning. A practitioner of brief counselingshould continue to provide support, feed-back, and assistance in setting, achieving,

and maintaining realistic goals. This willinvolve helping the patient identify relapsetriggers and situations that could endangercontinued progress. Since patients receivingbrief counseling are currently experiencingalcohol-related harm, periodic monitoringas appropriate for the degree of risk dur-ing and (for a time) after the counselingsessions is essential. If the patient is mak-ing progress toward a goal or has achievedit, such monitoring may be reduced to asemi-annual or annual visit. However, if thepatient continues for several months tohave difficulties reaching and maintainingthe drinking goal, consideration should begiven to moving the patient to the nexthighest level of intervention, referral toextended treatment if it is available. If suchspecialized treatment if not available, reg-ular monitoring and continued counselingmay be necessary.


Box 6

Working with Illiterate PatientsPatients who are illiterate or have poorreading ability will require specialhelp in brief counseling situations. Itis recommended that the health careworker review the self-help bookletwith the patient, assist in filling outthe plan, and (if the patient is will-ing) suggest that the patient give thematerials to a friend or family mem-ber who might assist in remindingthe patient of its contents.

Preparation

Abrief intervention should not be usedas a substitute for care of patients

with a moderate to high level of alcoholdependence. It can, however, be used toengage patients who need specializedtreatment. In preparation for using a briefintervention to motivate patients to accepta referral for diagnostic evaluation andpossible treatment, it will be necessary tocompile information about treatmentproviders and, if possible, visit these pro-grams to establish personal contacts thatcan be used to facilitate a referral.

A list of all alcohol treatment providersshould be made for the entire region,including the services offered by each.Record names, phone numbers, andaddresses of the facilities, as well as otherinformation that is relevant to yourpatients. This might include outpatient,day treatment, residential, and detoxifica-tion programs as well as mental healthfacilities that can address the psychiatricaspects of alcohol dependence. In addi-tion, any halfway houses and grouphomes should be identified for thosepatients in need of living arrangements.Finally, the list should include local mutualhelp groups like Alcoholics Anonymous,as well as individual alcohol counselors inthe area. Other community services thatmay be helpful to patients, such as voca-tional rehabilitation and crisis services,should also be identified.

Referral for Zone IV Drinkers with Probable Alcohol Dependence

Who Requires Referral toDiagnosis and Treatment?

Patients who score 20 or more on theAUDIT screening test are likely to requirefurther diagnosis and specialized treat-ment for alcohol dependence. It shouldbe remembered, however, that the AUDITis not a diagnostic instrument, and it istherefore unwarranted to conclude (orinform the patient) that alcohol depen-dence has been formally diagnosed.

In addition, certain persons who scoreunder 20 on the AUDIT, but who are notappropriate for simple advice or briefcounseling, should be referred to specialtycare. These may include:

■ persons strongly suspected of having analcohol dependence syndrome;

■ persons with a prior history of alcoholor drug dependence (as suggested byprior treatment) or liver damage;

■ persons with prior or current seriousmental illness;

■ persons who have failed to achievetheir goals despite extended brief coun-seling.

Providing Referral toDiagnosis and Treatment

The goal of a referral should be to assurethat the patient contacts a specialist forfurther diagnosis and, if required, treat-ment. While most patients know how

REFERRAL FOR RISK ZONE IV DRINKERS WITH PROBABLE ALCOHOL DEPENDENCE I 27

much they are drinking, many are resis-tant to taking immediate action to change.The reasons for such resistance include:

■ not being aware their drinking is excessive;

■ not having made the connectionbetween drinking and problems;

■ giving up the benefits of drinking;

■ admitting their condition to themselvesand others; and

■ not wanting to expend the time andeffort required by treatment.

The effectiveness of the referral process islikely to depend upon a combination ofthe health care provider’s authority and thedegree to which the patient can resolvesuch resistance factors. A modified formof simple advice is useful for making areferral, using feedback, advice, responsi-bility, information, encouragement, andfollow-up.

Feedback

Reporting the results of the AUDIT screen-ing test should make clear that:

■ the patient’s level of drinking farexceeds safe limits,

■ specific problems related to drinking arealready present, and

■ there are signs of the possible presenceof alcohol dependence syndrome.

It may be helpful to emphasize that suchdrinking is dangerous to the patient’sown health, and potentially harmful to

loved ones and others. A frank discussionof whether the patient has tried unsuc-cessfully to cut back or quit may assist thepatient in understanding that help maybe required to change.

Advice

The health care worker should deliver theclear message that this is a serious medicalcondition and the patient should see a spe-cialist for further diagnosis and possiblytreatment. The possible connection ofdrinking to current medical conditions shouldbe drawn, and the risk of future healthand social problems should be discussed.

Responsibility

It is important to urge the patient to dealwith this condition by seeing the specialistand following recommendations. If thepatient indicates such willingness, infor-mation and encouragement should beprovided. If the patient is resistant, anoth-er appointment may be needed to allowthe patient time to reflect on the deci-sion.

Information

Patients who have not previously soughttreatment for alcohol problems may needinformation about what is involved. Afterdescribing the health workers they willmeet and the treatment they will receive,patients are likely to be more receptive tomaking a decision to enter treatment.


Encouragement

Patients in this situation are likely to ben-efit from words of assurance and encour-agement. They should be told that treat-ment for alcohol dependence is generallyeffective, but that considerable effort maybe needed on their part.

Follow-up

Following alcohol treatment, patientsshould be monitored in the same way aprimary care provider might monitorpatients being treated by a cardiologist ororthopedist. This is particularly importantbecause the alcohol dependence syn-drome is likely to be chronic and recur-ring. Periodic monitoring and supportmay help the patient resist relapse or tocontrol its course if it occurs.

REFERRAL FOR RISK ZONE IV DRINKERS WITH PROBABLE ALCOHOL DEPENDENCE I 29

A Note on Adaptation and Use

The brochure reproduced in this appen-dix is based on the guide to low-risk

drinking that was used to provide simpleadvice to hazardous and harmful drinkersin the WHO Project on Identification and Management of Alcohol-RelatedProblems15, 17. The six panels can beprinted on two sides of a standard letter-sized paper and folded into three partswith the cover (Panel 1) on top.

The illustrations and guidelines providedin this version should be reviewed careful-ly in terms of their appropriateness fordifferent cultural groups and primary carepopulations. Each panel should be adapt-ed to the circumstances of the screeningand brief intervention programme con-ducted in a given setting and country. Thepercent figures in The Drinkers’ Pyramidof Panel 2 represent the proportion of thepopulation who are that type of drinker.These figures should be based on localsurvey data or estimates of the propor-tions of people representing each type ofdrinker. In some countries, the propor-tions of abstainers, low-risk drinkers, riskydrinkers, and persons with alcohol depen-dence (alcoholics) may vary considerably.Guidelines for the “Low-Risk Limit” (Panel5) can be modified to fit national policyand/or local circumstances. Different limitsfor males, females, and the elderly maybe cited. Similarly, the list of activities in which people should not drink at allshould be customized to fit culturally specific conditions. Finally, Panel 6,

“What’s a Standard Drink?”, should bemodified to show local alcoholic bever-ages that are comparable in theirabsolute alcohol content.

If the population where the brochure isdistributed contains a large number ofpersons who are illiterate or have limitedreading abilities, emphasis should begiven to the visual illustrations in theadaptation of the leaflet.

What is a Standard Drink?

In different countries, health educatorsand researchers employ different defini-tions of a standard unit or drink becauseof differences in the typical serving sizesin that country. For example,

■ 1 standard drink in Canada: 13.6 grammes of pure alcohol

■ 1 standard drink in the UK: 8 grammes

■ 1 standard drink in the USA: 14 grammes

■ 1 standard drink in Australia or NewZealand: 10 grammes

■ 1 standard drink in Japan: 19.75 grammes

In the AUDIT, Questions 2 and 3 assumethat a standard drink equivalent is 10grams of alcohol. You may need to adjustthe number of drinks in the response cat-egories for these questions in order to fitthe most common drink sizes and alcoholstrength in your country.


Appendix APatient Education Brochure

The recommendation for low-risk drinkinglevel set in the Guide to Low-RiskDrinking and used in the WHO study onbrief interventions is no more than 20grams of alcohol per day, 5 days a week(recommending at least 2 non-drinkingdays).

How to Calculate the Content ofAlcohol in a Drink

The alcohol content of a drink dependson the strength of the beverage and thevolume of the container. There are widevariations in the strengths of alcoholicbeverages and the drink sizes commonlyused in different countries. A WHO survey21

indicated that beer contained between2% and 5% of pure alcohol, wines con-tained 10.5% to 18.9%, spirits variedfrom 24.3% to 90%, and cider from1.1% to 17%. Therefore, it is essential toadapt drinking sizes to what is most com-mon at the local level and to knowroughly how much pure alcohol the person consumes per occasion and on average.

Another consideration in measuring theamount of alcohol contained in a standarddrink is the conversion factor of ethanol.That allows you to convert any volume ofalcohol into grammes. For each milliliter ofethanol, there are 0.79 grammes of pureethanol. For example,

■ 1 can beer (330 ml) at 5% (strength) x 0.79 (conversion factor)= 13 grammes of ethanol

■ 1 glass wine (140 ml) at 12% (strength) x 0.79 = 13.3 grammesof ethanol

■ 1 shot spirits (40 ml) at 40% (strength) x 0.79 = 12.6 grammesof ethanol

APPENDIX A I 31

A Guide to Low-Risk Drinking


Panel 1

APPENDIX A I 33

Panel 2

The Drinkers’ Pyramid

5%

20%

40%

35%

Probable Alcohol Dependence

High-Risk Drinkers

Low-Risk Drinkers

Abstainers

20+

AUDIT Scores Types of Drinkers

8 – 19

1 – 7

0


Panel 3

Numb, tingling toes.Painful nerves.

Impaired sensationleading to falls.

Inflammation of the pancreas.

Vitamin deficiency. Bleeding.Severe inflammation

of the stomach. Vomiting.Diarrhea. Malnutrition.

Cancer of throat and mouth .

Premature aging. Drinker's nose.

Weakness of heart muscle.Heart failure. Anemia.

Impaired blood clotting.Breast cancer.

In men: Impaired sexual performance.

In women:Risk of giving birth to deformed,

retarded babies or low birthweight babies.

Aggressive,irrational behaviour.Arguments. Violence.Depression. Nervousness.

Frequent colds. Reducedresistance to infection.Increased risk of pneumonia.

Alcohol dependence.Memory loss.

Ulcer.

Liver damage.

Trembling hands.Tingling fingers.Numbness. Painful nerves.

High-risk drinking may lead to social, legal, medical, domestic, job and financialproblems. It may also cut your lifespan and lead to accidents and death from drunk-en driving.

Effects of High-Risk Drinking

Panel 4

APPENDIX A I 35

Should I Stop Drinking or Just Cut Down?

You should stop drinking if :

■ You have tried to cut down before but have not been successful,

or

■ You suffer from morning shakes during a heavy drinking period,

or

■ You have high blood pressure, you are pregnant, you have liver disease,

or

■ You are taking medicine that reacts with alcohol.

You should try to drink at low-risk levels if :

■ During the last year you have been drinking at low-risk levels most of the time,

and

■ You do not suffer from early morning shakes,

and

■ You would like to drink at low-risk levels.

Note that you should choose low-risk drinking only if all three apply to you.


Panel 5

What’s a Low-Risk Limit?

■ No more than two standard drinks a day

■ Do not drink at least two days of the week

But remember. There are times when even one or two drinks can be too much – for example:

■ When driving or operating machinery.

■ When pregnant or breast feeding.

■ When taking certain medications.

■ If you have certain medical conditions.

■ If you cannot control your drinking.

Ask your health care provider for more information.

APPENDIX A I 37

Panel 6

1 can of ordinary beer (e.g. 330 ml at 5%)

A glass of wine or a small glass of sherry(e.g. 140 ml at 12% or 90 ml at 18%)

A small glass of liqueur or aperitif(e.g. 70 ml at 25%)

or

or

or

How Much is Too Much? The most important thing is the amount of pure alcohol ina drink. These drinks, in normal measures, each contain roughly the same amountof pure alcohol. Think of each one as a standard drink.

What’s a Standard Drink?

1 standard drink =

A single shot of spirits (whiskey, gin, vodka, etc.)(e.g. 40 ml at 40%)

A Note on Adaptation and Use

This booklet is based on “How to PreventAlcohol-Related Problems: A SensibleDrinking Manual” that was developed byR. Hodgson to provide brief counseling inthe WHO Project on Identification andManagement of Alcohol-RelatedProblems15, 17. The guidelines provided inthis generic version should be reviewedcarefully in terms of their appropriatenessfor different cultural groups and primarycare populations. Each section should beadapted to the circumstances of thescreening and brief intervention pro-gramme conducted in a given setting andcountry. For example, the section on“Good Reasons for Drinking Less” pro-vides a list of possible motives people useto convince themselves that they shouldreduce their drinking. These motives maydiffer according to gender, culture, andage. If the examples listed in the bookletare not appropriate for your patients,please change them to fit the needs ofthe people you are interested in reaching.

If the population where the booklet is dis-tributed contains a large number of per-sons who are illiterate or have limitedreading abilities, emphasis should begiven to the development of visual illus-trations and the booklet can be reviewedorally with the patient.


Appendix BSelf-Help Booklet

Who is This Booklet For?

This booklet is not only for people whohave drinking problems, it is also forthose people who are drinking smalleramounts of alcohol but are drinkingenough to be at risk of developing futurehealth problems.

The advice given in this booklet will helpboth those people who have drinkingproblems and those who want to preventfuture problems. The booklet provides:

■ Advice on low-risk drinking limits

■ Good reasons for drinking at low-risklevel

■ Advice on changing habits

The emphasis is on changing habits andpreventing future problems.

Contents

■ What is low-risk drinking?

■ How you can change your drinking habits?

■ Good reasons for drinking less

■ High-risk situations

■ What to do when you are tempted

■ People need people

■ What to do about boredom

■ How to stick to your plans

■ Guidelines for Helpers

■ Creating your habit-breaking plan

What is Low-Risk Drinking?

Low-risk drinking involves limiting alcoholuse to amounts and patterns that areunlikely to cause harm to oneself or oth-ers. Scientific evidence indicates that therisk of harm increases significantly whenpeople consume more than two drinksper day and more than five days perweek. Moreover, even smaller amounts ofalcohol present risks in certain circum-stances. Following the simple rules belowcan reduce the risk to your health and thepossibility you might hurt someone else:

■ Have no more than two drinks of alco-hol per day

■ Drink no more than five days per week

■ Do not use any alcohol at times whenyou:

■ Drive or operate machinery

■ Are pregnant or breast feeding

■ Are taking medications that reactwith alcohol

■ Have medical conditions made worseby alcohol

■ Cannot stop or control your drinking

Ask your health care worker for moreinformation about situations in which youshould limit your drinking.

These low-risk drinking limits are basedupon “standard” measures of alcohol. Itis important for you to determine howmuch alcohol is in each beverage youusually drink. Most bottles and cans ofbeer have about the same amount of

APPENDIX B I 39

How to Prevent Alcohol-Related ProblemsA Self-help Booklet

alcohol as a glass of wine or one shot ofdistilled spirits. When you think abouthow much you drink, be sure to countstandard drinks.

If you have been drinking above these lim-its, you risk causing harm to yourself andothers. Having three or more drinks onone occasion creates risks of “accidents”involving injuries, problems in relation-ships and at work, and medical problemssuch as hangovers, sleeplessness, andstomach problems. Drinking more thantwo drinks per day over extended periodsmay cause cancer, liver disease, depres-sion, and dependence on alcohol (alco-holism).

Fortunately, most people can stop or reducetheir drinking if they decide to do so andwork hard at changing their drinking habits.The following sections will tell you how.

How You Can Change YourDinking Habits

When people successfully change theirhabits they usually follow a simple plan.This manual will help you to produce asensible drinking plan. If possible, try toget somebody to help you. Perhaps afriend or a relative, a health worker ormember of your religious communitywould be willing and able to help youwork out a plan and stick to it. Ask thatperson to read this booklet first.

The reason for getting somebody elseto help is simply that two heads arebetter than one. Also, they will beable to provide some support.

Another way of using this manual isto get together with one or two otherpeople who also want to change theirdrinking habits.

Of course, many people change theirhabits without help from others. If youare unable to get somebody else to help,then work out a plan by yourself.

First, you should ask yourself the followingquestions:

■ How will I benefit if I cut down on my drinking?

■ How will my life improve?

The next section will help you to answerthese questions.

Good Reasons for DrinkingLess

Based upon recent research on the effectsof alcohol, here is a list of benefits thatyou can reasonably expect if you cutdown on your drinking. Read throughthem and choose three that seem to bethe best reasons to you. Choose the onesthat make you want to cut down.


■ FOR WOMEN: There will be less chancethat I will damage my unborn child.

When you have chosen three good reasonsfor cutting down on your drinking, makea note of them in the spaces provided atthe end of this booklet under “CreatingYour Habit-Breaking Plan.”

Now you should have a clearer picture inyour mind of exactly what you expect tohappen if you continue to drink heavilyand a clearer picture of your future if youstop drinking or drink within low-risk lev-els.

High-Risk Situations

Your desire to drink heavily probablychanges according to your moods, thepeople you are with, and whether or notalcohol is easily available.

Think about the last time you drank toomuch and try to work out what thingscontributed to your drinking. What situa-tions will make you want to drink heavilyin the future? For example, here is oneperson's list:

■ Situations in which other people aredrinking and I am expected to drink.

■ Feeling bored and depressed, especiallyon weekends.

■ After a family argument.

■ When drinking with my friends.

■ When feeling lonely at home.

APPENDIX B I 41

If I drink within low-risk limits

■ I will live longer--probably between five and ten years.

■ I will sleep better.

■ I will be happier.

■ I will save a lot of money.

■ My relationships will improve.

■ I will stay younger for longer.

■ I will achieve more in my life.

■ There will be a greater chance that Iwill survive to a healthy old age withoutpremature damage to my brain.

■ I will be better at my job.

■ I will probably find it easier to stay slim,since alcoholic beverages contain manycalories.

■ I will be less likely to feel depressedand to commit suicide (6 times lesslikely).

■ I will be less likely to die of heart dis-ease or cancer.

■ The possibility that I will die in a fire orby drowning will be greatly reduced.

■ Other people will respect me.

■ I will be less likely to get into troublewith the police.

■ The possibility that I will die of liver disease will be dramatically reduced (12 times less likely).

■ It will be less likely that I will die in acar accident (3 times less likely).

■ FOR MEN: My sexual performance willprobably improve.

■ FOR WOMEN: There will be less chancethat I will have an unplanned pregnancy.

Use the following list to help you identifyfour situations in which you are most like-ly to drink too much:

Parties Particular people

Festivals Tension

Family Feeling lonely

Bars Dinner parties

Mood Boredom

After Work Sleeplessness

Arguments Weekends

Criticism After receiving pay

Feelings of failure When others are drinking

When you have chosen the four danger-ous situations or moods that give you themost trouble, write them down in thepages provided at the end of this bookletunder “Creating Your Habit-Breaking Plan.”The next task is to work out ways of deal-ing with these situations without drinkingmore than the recommended limits.

What to Do when You are Tempted

In this section try to answer the question:How can I make sure that I'm not temptedto drink too much and, if I am tempted,what can I do to stop myself?

This task is not easy but you may find iteasier if you get another person to helpand together you go through the follow-ing steps:


■ Choose one of your four high-risk situa-tions.

■ Think of different ways of avoiding orcoping with it.

■ Select two of these ways to try out.Write them down in Creating YourHabit-Breaking Plan at the end of thisbooklet.

Here is one man's attempt to work out away of coping with the temptation todrink with friends after work.

High-Risk Situation

Drinking with friends after work.

Ways of Coping Without Drinkingtoo Much

■ Go home rather than drinking

■ Find another activity, e.g., exercise

■ Limit the number of days drinking afterwork with friends

■ Have only two drinks when drinking

■ Switch to non-alcoholic beverages aftertwo drinks

■ Change friends

■ Work later

Two that I will try:

■ Limit the number of days drinkingafter work with friends

■ Switch to non-alcoholic beveragesafter two drinks

Notice that some of the ideas probablywould not work. This doesn't matterwhen trying to produce ideas. Just thinkof as many as you can and then decidewhich ones are the most likely to workfor you. When you have selected twoways of coping with your first high risksituation, move on to the next one sothat you end up with two ways of copingwith each of the four high-risk situations.

The next area of your life that you shouldthink about is the relationship that youhave with other people. If you can increasethe number of times each week that youenjoy the company of other people (with-out drinking above sensible limits), thenyou will not need to use alcohol as much.

People Need People

The first point to remember is that mostof us need other people. We need tosocialize. Secondly, one of the best waysof encouraging yourself to drink at low-risk levels is by having friends who drinkwithin low-risk limits. Thirdly, you willincrease your chances of making newsocial contacts if you put yourself in situa-tions where you will meet new people.Therefore, the next task that you shouldset for yourself is to think of ways ofputting yourself in such situations. Again,use the method of thinking of as manyideas as you can and then choose twothat are most likely to work for you. Hereis an example:

APPENDIX B I 43

Problem

To put myself in situations where I will be involved with other people who drinkwithin low-risk limits.

Ideas

■ Join a club

■ Help with religious activities or the Community Center

■ Help out at my son or daughter'sschool or Youth Club

■ Join a voluntary organization (e.g., helping the handicapped)

■ Invite people home more often

■ Visit relatives more often

What to Do about Boredom

Many people drink because they arebored. If boredom contributes to yourdrinking beyond low-risk limits, your taskin this section is to think of as many activ-ities as you can that might hold yourinterest and then select two of them totry. Use the following questions to helpproduce this list.

■ What types of things have you enjoyedlearning in the past? (e.g., sports,crafts, languages)

Write down the two ways of meet-ing other low-risk drinkers that youchoose under Creating Your Habit-Breaking Plan.

■ What types of trips have you enjoyed inthe past? (e.g., to the ocean, to themountains, to the country)

■ What types of things do you think youcould enjoy if you had no worries aboutfailing? (e.g., painting, dancing)

■ What have you enjoyed doing alone?(e.g., long walks, playing a musicalinstrument, sewing)

■ What have you enjoyed doing with others? (e.g., talking on the telephone,playing a game)

■ What have you enjoyed doing that costsno money? (e.g., playing with your chil-dren, going to the library, reading)

■ What have you enjoyed doing thatcosts very little (e.g., going to a park)

■ What activities have you enjoyed at different times? (e.g., in the morning,on your day off work, in the spring, inautumn)

Write down the two activities that youchoose under Creating Your Habit-BreakingPlan.

The two ways of avoiding boredomto try:

■ Join a community group (in thelibrary, church, women's organi-zation etc. or adult educationcourse like crafts, painting, etc.)

■ Exercise regularly (swimming, jog-ging, etc.) or join a sport club


A Note on Depression

Many people drink because they aredepressed. Depression is characterized byfeelings of sadness, loss of interest in activi-ties, and decreased energy. Other symp-toms include loss of confidence and self-esteem, inappropriate guilt, thoughts ofdeath and suicide, diminished concentra-tion, and disturbance of sleep and appetite.

If you have felt depressed for two weeksor more, you need to get help from ahealth worker. Treatment does help. Duringtreatment for depression you should stopdrinking, as alcohol is a depressant drugthat will delay your response to treatment.

How to Stick to Your Plans

First of all, complete and save the sectionon Creating Your Habit-Breaking Plan.This is your master plan for the next fewweeks. You must go over your plan eachday. If you don't, you will just forgetabout it, especially when you are facedwith a dangerous or tempting situation.Here is the best way of insuring that youkeep your plan in mind.

■ Think of an activity that you do severaltimes every day (e.g., drinking a cup ofcoffee, washing your hands).

■ Whenever you carry out that activity(e.g., drinking coffee), very quickly goover the plan in your mind. Think aboutyour drinking plan, reasons for cuttingdown, dangerous situations and waysof coping with them. Also think of your

plans for meeting other people andbeginning interesting activities.

■ If you have a helper, talk about yourplan and progress every day at first andthen several times a week as you havesuccess sticking to it.

■ If your plan is clearly in your mind, thenit will help you to change. If it is onlyon paper it will have no effect at all.Here are a few other tips:

■ Remember that every time you aretempted to drink too much and areable to resist, you are breaking yourhabit.

■ Whenever you feel very uncomfortable,distressed or miserable, keep tellingyourself that it will pass. If you crave adrink, pretend that the craving is like asore throat that you have to put upwith until it goes away.

■ If you have a helper, tell that personhonestly how much you had to drinkeach day and when you have been suc-cessful or have drunk too much.

■ Finally, it is likely that you will havesome bad days on which you drink toomuch. When that happens, DON'T GIVEIN. Remember that people who HAVElearned to drink at low-risk levels hadmany bad days before they were finallysuccessful. It will get easier in time.

Guidelines For Helpers

It is sometimes easier to read a bookletand work out a plan for changing habitswith the help of somebody else. Twoheads are sometimes better than one.That is why we have encouraged people

APPENDIX B I 45

who are using this manual to ask some-body else to go through it with them. Ifyou are willing to help in this way thenyou might find it useful to bear in mindthe following points:

■ This booklet has been produced withtwo types of drinkers in mind. Some arealready having problems with drinkingand want to change. Others are drink-ing smaller amounts of alcohol that putthem at risk of developing problems.They have been advised to cut down in order that future problems can beavoided. Prevention is better than cure.

■ The main aims of the manual are tofind good reasons for drinking less andalso to develop other activities insteadof drinking.

■ Changing habits is a difficult task butyou can help in two ways. First, you canhelp with the exercises provided in thebooklet. Second, you can provideencouragement and support.

■ Try not to criticize the person you arehelping, even if you get annoyed andfrustrated with his or her behaviour.Remember that changing habits isnever easy. There are bound to be goodweeks and bad weeks. Your encourage-ment, support of low-risk drinking orabstinence, and creative ideas are need-ed.


Creating Your Habit-Breaking Plan

Reasons for cutting down or stopping drinking

1.2.3.

Dangerous Situation 1

Ways of coping:1.2.


Ways of coping:1.2.


Ways of coping:1.2.


Ways of coping:1.2.

Ways of meeting others who don t drink or do so within low-risk limits1.2.

Ways of avoiding boredom to try1.2.

How to remember your plan1.2.

A Simple Training Exercise

Asimple role-play exercise can be usedto allow the health worker to practice

screening and simple advice with a “sim-ulated patient”. Choose a fellow traineeas a partner. One partner should play therole of the “high-risk drinker” while theother plays the role of a “health worker”.The “health worker” should administerthe AUDIT screening interview and thengive the simple advice using A Guide toLow-Risk Drinking. Introduce the AUDITby giving your partner a general idea ofthe content of the questions. Use theinformation concerning any alcohol-relat-ed problems you identify during thescreening as part of your simple advice toyour partner. Don’t forget your transition-al statement when introducing the Guideto Low-Risk Drinking. The two partnersshould then exchange roles.

After completing your practice, commenton interview style, including transitionalstatements, clarity of explanations, and useof pertinent information from the screeningtest while giving brief advice. Also commenton style and rapport: Was the interviewerfriendly and non-threatening? Was thepurpose of the screening explained to thepatient? Did the interviewer stress confi-dentiality? Did the drinker answer in termsof “standard drinks”. If not, did the inter-viewer probe the answers?

Training Programs

Several training programs have beendeveloped to prepare primary care health

workers to conduct screening and briefinterventions. The procedures described inthis manual can be taught to individualsand groups by means of a training manualand videotapes developed by the Universityof Connecticut (McRee et al., 1992). Thisand other resources are listed below.

Alcohol risk assessment and intervention(ARAI) package. Ontario, College ofFamily Physicians of Canada, 1994.

Guide to clinical preventive services. Reportof the U.S. Preventive Services Task Force.Baltimore, Williams and Wilkins, 1989.

Anderson, P. Alcohol and primary healthcare. Copenhagen, WHO, Regional Officefor Europe, 1996 (WHO RegionalPublications, European Series, No. 64).

Heather, N. Treatment approaches toalcohol. Copenhagen, WHO RegionalOffice for Europe, 1995 (WHO RegionalPublications, European Series, No. 65).

Hester, R.K. and Miller, W.R. (Eds)Handbook of Alcoholism TreatmentApproaches: Effective Alternatives.Elmsdorf, NY: Pergamon Press, 1989.

McRee, B., Babor, T.F. and Church, O.M.Alcohol Screening and Brief Intervention.Project NEADA, University of Connecticut,School of Nursing, 1992. Ordering infor-mation may be obtained from: the U.S.National Clearinghouse on Alcohol andDrug Information: www.health.org or call1-800-729-6686.

APPENDIX C I 47

Appendix CTraining Resources

Miller, W.R. Enchancing motivation forchange in substance abuse treatment. U.S.Department of Health and Human Services,SAMHSA/CSAT, Rockville, MD, 1999.

National Institute on Alcohol Abuse andAlcoholism (NIAAA). Training Physicians inTechniques for Alcohol Screening and BriefIntervention. National Instititues ofHealth: Bethesda, MD 1997.

Sanchez-Craig, M. A Therapist’s Manual:Secondary Prevention of Alcohol Problems.Addiction Research Foundation, Toronto,Canada, 1996.

Sanchez-Craig, M. Drink Wise: How toQuit Drink or Cut Down. AddictionResearch Foundation, Toronto, Canada,1994.

Sullivan, E.. and Fleming, M. A Guide toSubstance Abuse Services for Primary CareClinicians. Treatment Improvement ProtocolSeries. U.S. Department of Health andHuman Services, Rockville, MD, 24; 1997.


1. Babor, T.F., Higgins-Biddle, J.C.,Saunders, J.B. and Monteiro, M.G.AUDIT The Alcohol Use DisordersIdentification Test: Guidelines for Usein Primary Care. Second Edition.World Health Organization, Geneva,2001.

2. Heather, N. Treatment Approaches to Alcohol Problems. World HealthOrganization, Copenhagen, 1995(WHO Regional Publications, EuropeanSeries, No. 65).

3. Hester, R.K. and Miller, W.R. (Eds)Handbook of Alcoholism TreatmentApproaches: Effective Alternatives.Allyn and Bacon, Boston 1995.

4. World Health Organization. The ICD-10Classification of Mental and BehaviouralDisorders: Diagnostic Criteria forResearch. World Health Organization,Geneva, 1993.

5. Anderson, P. Alcohol and Primary HealthCare. World Health Organization,Copenhagen, 1996 (WHO RegionalPublications, European Series No. 64).

6. Edwards, G., Anderson, P., Babor, T.F.,Casswell, S., Ferrence, R., Geisbrecht,N., Godfrey, C., Holder, H., Lemmens,P., Makela, K., Midanik, L., Norstrom,T., Osterberg, E., Romelsjo, A., Room,R., Simpura, J. and Skog., O. AlcoholPolicy and the Public Good. OxfordUniversity Press, Oxford, 1994.

7. Institute of Medicine. Broadening the Base of Treatment for Alcohol

Problems. National Academy Press,Washington, DC, 1990.

8. Makela, K. International comparisons ofAlcoholics Anonymous. Alcohol Health& Research World 17:228-234, 1993.

9. Bien, T, Miller, W.R. and Tonigan, J.S.Brief interventions for alcohol prob-lems: A review. Addiction 88: 315-336, 1993.

10. Kahan, M., Wilson, L. and Becker, L. Effectiveness of physician-basedinterventions with problem drinkers: Areview. Canadian Medical AssociationJournal 152(6):851-859, 1995.

11. Wilk, A., Jensen, N. and Havighurst, T. Meta-analysis of randomized controltrials addressing brief interventions inheavy alcohol drinkers. Journal ofGeneral Internal Medicine 12:274-283, 1997.

12. Moyer, A., Finney, J., Swearingen, C.and Vergun, P. Brief interventions foralcohol problems: A meta-analyticreview of controlled investigations intreatment-seeking and non-treatmentseeking populations. Addiction (inpress).

13. Saunders, J.B., Aasland, O.G., BaborT.F., De la Fuente, J.R. and Grant, M.Development of the Alcohol UseDisorders Identification Test (AUDIT):WHO collaborative project on earlydetection of persons with harmfulalcohol consumption. Addiction88:791-804, 1993.

REFERENCE I 49

References

14. Orford, J. Empowering family andfriends: a new approach to the sec-ondary prevention of addiction. Drugand Alcohol Review, 13: 417-429,1994.

15. Babor, T.F. and Grant, M. (Eds).Project on identification and manage-ment of alcohol-related problems.Report on Phase II: A randomizedclinical trial of brief interventions inprimary health care. Programme onSubstance Abuse, World HealthOrganization, Geneva, 1992.

16. Babor, T.F. and Higgins-Biddle, J.C.Alcohol screening and brief interven-tion: Dissemination strategies formedical practice and public health.Addiction 95(5):677-686, 2000.

17. WHO Brief Intervention Study Group.A cross-national trial of brief interven-tions with heavy drinkers. AmericanJournal of Public Health, 86(7): 948-955, 1996.

18. Ashley, M.J., Ferrence, R., Room, R., Rankin, J., & Single, E. Moderatedrinking and health: Report of aninternational symposium. CanadianMedical Association Journal 151:1-20,1994.

19. Miller, W.R. Enhancing motivation forchange in substance abuse treatment.U.S. Department of Health and HumanServices, SAMHSA/CSAT, Rockville, MD,1999.

20. Prochaska, J. O. and DiClemente, C.C. Stages and processes of self-change of smoking: Toward an inte-grative model of change. Journal ofConsulting and Clinical Psychology51(3): 390-395, 1983.

21. Finnish Foundation for Alcohol Studies.International Statistics on AlcoholicBeverages: Production, Trade andConsumption 1950-1972. Helsinki,Finnish Foundation for AlcoholStudies, 1977.


Notes

NOTES I 51


Documents

BRIEF INTERVENTION - WHOapps.who.int/iris/bitstream/10665/67210/1/WHO_MSD_MSB_01.6b.pdf · World Health Organization BRIEF INTERVENTION For Hazardous and Harmful Drinking A Manual