Download Briefing Paper Delivering Alcohol Brief Advice

Briefing Paper
Delivering Alcohol
Brief Advice
Author: Su Mably Consultant in Public Health; Craig Jones Public Health
Practitioner (Alcohol)
Date: 26 July 2010
Version: 0f
Publication/ Distribution:

Intranet/ Internet
Review Date: April 2011
Purpose and Summary of Document:
This briefing paper has been developed by Public Health Wales at the
request of the Welsh Assembly Government, to support practitioners in
delivering brief advice on alcohol use. The purpose of this paper is to
introduce practitioners to key terms relating to brief advice, to provide
relevant background information, to describe the evidence based approach
to brief advice recommended by Public Health Wales and to provide answers
to some of the frequently asked questions.
Work Plan reference: Alcohol PLA 2010/ 2011
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
Contents
1
BACKGROUND ......................................................................... 4
2
THE SCALE OF ALCOHOL MISUSE IN WALES: WHY IS IT A
PUBLIC HEALTH PRIORITY ..................................................... 4
2.1 Morbidity and Mortality .......................................................... 5
2.2 Effect of Alcohol Misuse on others ........................................... 6
3
DEFINING ALCOHOL BRIEF ADVICE ........................................ 6
3.1 Hazardous and Harmful Drinking ............................................ 7
4
CALCULATING A UNIT OF ALCOHOL ........................................ 9
5
THE APPROACH ....................................................................... 9
6
THE EVIDENCE BASE ............................................................. 10
7
TIMESCALES FOR DELIVERY ................................................. 10
8
SUITABILITY OF BRIEF ADVICE ............................................ 11
9
WHEN BRIEF ADVICE IS NOT SUITABLE ............................... 11
10 SETTINGS ............................................................................. 12
11 PUTTING BA INTO PRACTICE ................................................ 12
12 WHEN TO ASK ABOUT ALCOHOL ........................................... 13
12.1 Social issues ....................................................................... 14
12.2 Occupational effects ............................................................. 14
12.3 Effects on mental health ....................................................... 14
12.4 Effects on physical health ..................................................... 14
13 TAKING THE FIRST STEP: RAISING THE ISSUE OF ALCOHOL 15
14 ALCOHOL BRIEF ADVICE – THE VITAL INGREDIENTS ........... 16
14.1 Rapport and empathy ........................................................... 16
14.2 Personal Responsibility ......................................................... 16
15 SCREENING/IDENTIFCATION TOOLS .................................... 17
15.1 Knowing who will benefit from Brief Advice ............................. 17
15.2 Alcohol Screening Tools Available .......................................... 18
15.2.1
Primary Care, Health Checks and A&E settings ................. 18
15.2.2
Antenatal settings ......................................................... 18
Date: 26 July 2010
Version: 0f
Page: 2 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
16 DELIVERY OF BA ................................................................... 19
17 SUMMARY OF THE FIVE ALCOHOL BRIEF APPROACHES ........ 20
17.1 Information and Advice (with permission) ............................... 20
17.2 Enhancing motivation ........................................................... 20
17.3 Menu of options ................................................................... 20
17.4 Building Confidence .............................................................. 21
17.5 Coping Strategies ................................................................ 21
18 APPROPRIATE REFERRAL TO ANOTHER SERVICE OR
PROFESSIONAL .................................................................... 21
19 SUMMARY ............................................................................. 22
20 FREQUENTLY ASKED QUESTIONS.......................................... 22
20.1 Common concerns about providing Brief Advice in practice ....... 22
Most of the people I help don’t want to change their drinking
pattern. How do I know that this will really work? ................. 22
20.2 Questions about current drinking limits .................................. 23
What about the reported benefits of alcohol- are they true? .............. 24
21 WHAT TRAINING WILL I NEED TO DELIVER BRIEF ADVICE? 25
22 FURTHER READING ............................................................... 26
22.1 Screening ........................................................................... 26
22.2 Brief Interventions/Advice ..................................................... 26
23 REFERENCES ......................................................................... 26
Date: 26 July 2010
Version: 0f
Page: 3 of 28
Public Health Wales
1
Briefing Paper Delivering Alcohol Brief
Advice
Background
The Welsh Assembly Government’s 10 year strategy ‘Working Together to
Reduce Harm’32 describes how the harm associated with substance misuse
in Wales will be tackled. In respect of alcohol, the focus is set on those
drinkers whose drinking levels or patterns are causing them longer term
damage or are causing problems for the wider community but who may
not need specialist treatment for addiction.
There is a clear consensus of the need to prevent longer term health
damage caused by hazardous and harmful consumption of alcohol,
recognising that the harmful use of alcohol in Wales is far more
widespread than that of illicit drugs. Those at risk of harm from alcohol
misuse come from across the spectrum of society. They include chronic
heavy drinkers, adults at home drinking at hazardous or harmful levels,
and children and young adults who suffer from, and who cause, much of
the alcohol related violence and disorder on our streets – often as result of
binge drinking32.
The Welsh Assembly Government are providing guidance and support to
the NHS and others to promote the appropriate provision of alcohol brief
advice, which has been shown to be effective in reducing people’s
drinking.18 + 25
This briefing paper is intended to support practitioners in delivering brief
advice on alcohol (see below for a description of alcohol brief advice). This
paper seeks to establish a common national understanding of key terms
and background information, in order to assist practitioners, Health Boards
and others with the planning and implementation of brief advice for
reducing alcohol misuse at a local level. Information on how to deliver
brief advice and a section on frequently asked questions are also included.
2
The Scale of Alcohol Misuse in Wales: why is
it a Public Health priority
A Profile of Alcohol and Health in Wales30, provides a detailed analysis of
the position in respect of alcohol consumption and harm in Wales. Nearly
45 per cent of adults in Wales admit to consuming more than the
recommended limits and 27 per cent admit to binge drinking31.
The comparison of alcohol sales with the reported alcohol use also
suggests that people are consuming more alcohol than they estimate they
are17. Alcohol consumption in the UK has increased over the past decade,
as have deaths and diseases related to alcohol 16, 14. The estimated health
Date: 26 July 2010
Version: 0f
Page: 4 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
service cost in Wales of alcohol related chronic disease and acute incidents
is between £70 million and £85 million each year6.
2.1
Morbidity and Mortality
Morbidity and mortality related to conditions most directly linked to
alcohol are referred to as “alcohol-related”, whilst “alcohol attributable”
mortality and morbidity refers to a new wider definition that includes
conditions in part linked to alcohol30.
The Patient Episode Database Wales provides information on hospital
admissions in the population of Wales:










The number of hospital discharges with an alcohol related diagnosis
increased by 20per cent from 2000 to 2005 with the most significant
increase occurring in the 35–44 age range.
A significantly higher level of individuals in the 50–54 age range is
being discharged from hospital with alcohol-induced (main or
contributory factor) chronic pancreatitis32.
The trend in both alcohol-related and alcohol-attributable hospital
admission rates is upwards, with rates approximately twice as high
for males than females. The average annual number of alcoholrelated hospital admissions for residents of Wales was around 8,400
for males and 4,500 for females (1.5per cent of all admissions).
Around 30,000 hospital bed days are related to alcohol every year6.
Liver disease (of which alcohol is a major cause) is responsible for
around 1,600 admissions every year 21. Hospital admissions for
alcohol related liver disease rose by over 25 per cent between 2000
and 200632.
Alcohol is a major contributing factor to the risk of cancer of the
breast, mouth, gullet, stomach, liver, pancreas, colon and rectum 21
There were around 15,300 referrals for treatment of alcohol misuse
in Wales in the year 2007-08; around 1,600 were for patients of
age. 19 and younger30. The medical profession in Wales are
reporting increasing numbers of younger people in the 25–34 age
group presenting with symptoms of alcohol related diseases32.
More people die from alcohol related causes than from breast
cancer, cervical cancer, and MRSA infection combined11.
Around 1,000 deaths are attributable to alcohol per year in Wales 30.
There were 260 alcohol-related deaths per year amongst males in
Wales compared to 670 alcohol-attributable deaths (4.3 per cent of
all male deaths) 30.
The alcohol-related mortality rate for males almost doubled in the
period of 1991-1993 to 2004-2006, although the trend has been
levelling out in the latest UK rates released by the Office for National
Statistics 30. The rate for persons in Wales in 2007 was slightly
Date: 26 July 2010
Version: 0f
Page: 5 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
higher than the rate for England, and just over half the rate for
Scotland 30.
2.2
Effect of alcohol misuse on others
Excessive alcohol consumption can also affect non-drinkers in many
different ways. This includes the impact of parental drinking on children,
the contribution of alcohol consumption to violent behaviour, drink driving,
fires and injuries, and the effect of drinking on relationships, families and
employment.




3
Alcohol is perceived to be a major cause of crime by around half of
respondents to the British Crime Survey. There were an estimated
18,000 incidents of violent crime attributable to alcohol in Wales in
the year 2007/08 30.
Almost half (46 per cent) of all incidents of domestic abuse are
linked to alcohol14.
44 per cent of 18-24 year olds in England and Wales report feeling
very drunk at least once month, two thirds of those, admit to
criminal and or disorderly behaviour during or after drinking15.
As many as 64,000 Welsh children may be adversely affected by
parental alcohol problems 21
Defining Alcohol Brief Advice
Alcohol brief advice is described as a short, evidence-based, structured
conversation about alcohol consumption with a client to motivate and
support the individual to think about and/or plan a change in their drinking
behaviour in order to reduce their consumption 22.
Brief advice is more than giving a patient/ client a leaflet and telling them
to read it.
Providing brief advice must have a structure and style that distinguishes it
from simply advising a person to drink less 1,29.
The provision of brief advice for alcohol misuse uses motivational
interviewing techniques, but does not require specialist expertise in these
techniques to guarantee effectiveness 25. FRAMES provides a useful
mnemonic to describe the approach.
FRAMES – stands for Feedback, Responsibility, Advice, Menu (of
options), Empathic interviewing, Self efficacy 25,29.
Motivational interviewing is a collaborative style of conversation that
Date: 26 July 2010
Version: 0f
Page: 6 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
practitioners can use to help patients explore and resolve their mixed
feelings about behavioural change in a way that enhances their motivation
and ability to make positive choices11. Brief advice is not the same as
alcohol counselling and the evidence suggests that brief advice on alcohol
can be effectively delivered by health professionals in a range of settings.
Practitioners should identify which of their clients could benefit from brief
advice – that is, they should ask a set of questions about the person’s
drinking, in order to make an objective assessment of their level of risk of
harm linked to their drinking behaviour. This enables the practitioner to
determine whether the client is a hazardous, harmful or dependent
drinker. This is referred to as ‘identification’ or ‘screening’.
3.1
Hazardous and harmful drinking
Recent developments in the terminology to describe drinking behaviours,
to enhance public understanding, are reflected in the following diagram
(see page 6). These are adapted from the Department of Health website
http://www.dh.gov.uk/en/index.htm (Accessed 28/09/09)
Date: 26 July 2010
Version: 0f
Page: 7 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
Figure 1. The Risks of Alcohol
Date: 26 July 2010
Version: 0f
Page: 8 of 28
Public Health Wales
4
Briefing Paper Delivering Alcohol Brief
Advice
Calculating a unit of alcohol
The strength of alcoholic drinks is measured in terms of the percentage of
alcohol by volume (% abv), which is the number of millilitres (ml) of pure
alcohol in 100ml of a particular drink. The average strength of a range of
alcoholic drinks has been increasing in recent years5. A unit of alcohol in
the UK has 10ml (8g) of pure alcohol (ethanol). This corresponds to
approximately:
• one 25ml measure of spirits (40% abv)
• half a 175ml glass (i.e. half a standard glass in most pubs) of
average-strength wine (12.5% abv)
• half a pint of normal-strength beer or lager (4 %).
It is generally more useful to think in terms of the approximate number of
units that are contained in a variety of common drinks, rather than what
constitutes one unit. For example:
• a 175ml glass of wine (12.5% abv) contains 2.2 units of
alcohol
• a home measure of spirits typically contains almost 2.5 units
of alcohol
• a pint of normal strength beer, lager or cider (4% abv)
contains 2.2 units of alcohol, whereas a pint of strong beer,
lager or cider (6.5% abv) contains 3.6 units of alcohol
• a 275ml bottle of alcopop (5% abv) contains 1.4 units of
alcohol
Drink Calculators, which can be used to calculate the number of units in
most alcoholic drinks, can be obtained from NHS Choice at
http://units.nhs.uk/
More information on alcohol units and how to
calculate them can be found at www.drinkwisewales.org.uk and
www.yfeddoethcymru.org.uk
Units = volume (ml) x abv (%) /1000
5
The Approach
When discussing alcohol with a client or asking them about their drinking
in order to provide brief advice, the purpose of the conversation is to:
• give them an opportunity to discuss their drinking if they
wish to do so;
• offer them feedback on how their drinking may affect their
health, particularly in relation to an issue or condition about
which they are concerned;
Date: 26 July 2010
Version: 0f
Page: 9 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
• explore how they feel about cutting down their alcohol
consumption or changing their drinking behaviour;
• help them to make changes if they want to do so22.
The patient is the expert on what changes, if any, are right for them. Any
reduction in drinking will reduce the health risks, but if the individual is
not interested in discussing their drinking, the practitioner should not
continue the conversation27.
6
The evidence base
Evaluation of brief interventions (hereafter brief advice) have consistently
shown them to be one of the most effective approaches to reducing
problem drinking25,1. Brief advice of various forms, delivered in a variety
of settings, have been shown to be effective in reducing alcohol
consumption among hazardous and harmful drinkers in a number of largescale reviews of research studies,19,2,4,23,7. There are a number of key UK
documents that have outlined the evidence for brief interventions in
primary care and Accident and Emergency (A & E) settings25 and this is
condensed in a National Public Health Service Report 20.
In particular, primary care has been shown to be an effective setting in
which to deliver brief interventions and through which to have a major
impact on public health25.
7
Timescales for delivery
Giving brief advice can take as little as five to 10 minutes to complete,
and even a single session with a client can be effective 25, 29.
In practice, the time that it takes to give brief advice will depend on a
variety of factors, including what the patient/ client wants and how they
feel about their drinking, the skills and confidence of the practitioner, the
level of drinking involved, and the time available for both client and
practitioner22.
If the practitioner or patient needs/wants to end the conversation at any
stage, the provider of the brief advice should ‘leave the door open’ for
further discussion at a later date.
There is no evidence that multiple sessions or follow-up sessions to
discuss alcohol consumption increase the effectiveness of the initial
intervention18.
By considering which approach to brief advice is most appropriate for each
patient/client, the amount of time spent discussing things that they
already know can be minimised. For example, some individuals may
already be aware that they drink too much and may not need further
Date: 26 July 2010
Version: 0f
Page: 10 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
information or advice about this. They may need to build their confidence
or consider their options for cutting down. Similarly, some people may not
want to cut down, in which case there would be little point in discussing
with them how to cope with stressful or high-risk situations.
If the individual is unsure whether they want to cut down, but there is not
enough time to fully explore the advantages and disadvantages of their
current drinking behaviour, the practitioner could give the person the
option of thinking about this themselves, away from the consultation. A
further option would be to refer the person to another service or
professional if they would benefit from, or are interested in, longer
discussion.
8
Suitability of brief advice
Brief advice is suitable for anyone who is regularly drinking more than the
recommended upper limit. The Department of Health advice on drinking
limits for people aged over 18 years in the UK is as follows:

For men, regular consumption of between three and four units of
alcohol a day, and no more than 21 in a week, by men is unlikely to
accrue significant health risks. Consistently drinking four or more
units of alcohol a day (or more than 21 units a week) is not advised.

For women, regular consumption of between two and three units a
day, and no more than 14 in a week, by women is unlikely to accrue
significant health risks. Consistently drinking three or more units of
alcohol a day (or more than 14 units a week) is not advised.
Pregnant women or women trying to conceive should avoid drinking
alcohol9.

All drinkers should have at least two alcohol-free days per week.
However, there are also many circumstances in which alcohol should not
be consumed. If adults are drinking alcohol in these circumstances, brief
advice may also be appropriate.
9
When brief advice is not suitable
There is no evidence to suggest that brief advice is effective in reducing
alcohol consumption among people who are dependent on alcohol25,29.
Alcohol dependence is a term used to describe a range of symptoms and
effects resulting from excessive alcohol consumption, where drinking
alcohol becomes a much higher priority for a particular individual than
Date: 26 July 2010
Version: 0f
Page: 11 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
other activities that previously had a greater value10. Other signs may
include a strong desire or sense of compulsion to take alcohol, physical
withdrawal symptoms or drinking to relieve or avoid withdrawal
symptoms, or evidence of alcohol tolerance.
It is important to raise the issue of alcohol with this high-risk group, some
of whom will wish to be referred to specialist services. Some people with
alcohol dependence recover without specialist treatment but current
evidence shows that brief interventions do not improve outcomes for this
group.
10
Settings
There is strong evidence25 that brief advice is effective in primary care and
some evidence of effectiveness in A & E departments. Thus it is proposed
that brief advice can be effectively delivered through:



doctors and nurses in the general practice setting in primary care
midwives and obstetricians in a primary care, community or hospital
setting
doctors or nurses as part of a patient’s care initiated in an A & E
department. The intervention may be delivered either in the A & E
department or during follow-on care from A & E in the acute setting,
such as an outpatient fracture clinic or in a hospital ward following
admission.
There is no evidence to suggest that brief advice sessions are
counterproductive in any setting, but further research is needed to
demonstrate their wider effectiveness25. There is a need to expand the
evidence base around brief advice in alternate settings and pilot work is
underway across the UK to test whether professionals other than those
based in primary care and A &E can effectively deliver brief advice.
The evidence on brief advice clearly indicates that ‘training is required in
order to deliver effective brief advice’ 25,29.
11
Putting brief advice into practice
There are two essential aspects to the delivery of brief advice – the what
is said and the how it is said.
Throughout the delivery of brief advice remember to maintain rapport and
empathy, whilst emphasising the client’s personal responsibility for their
decisions.
Date: 26 July 2010
Version: 0f
Page: 12 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
Figure 2.Delivering Alcohol Brief Advice
12
When to ask about alcohol
The following presentations should alert the practitioner to the possibility
that the issue of alcohol may be relevant:
Date: 26 July 2010
Version: 0f
Page: 13 of 28
Public Health Wales
12.1






12.2



12.3





12.4







Briefing Paper Delivering Alcohol Brief
Advice
Social issues
Relationship problems and domestic violence.
Criminal behaviour (e.g. driving offences, breach of the peace,
shoplifting).
Unsafe sex/sexual risk taking.
Personal risk taking.
Financial problems.
Bereavement (which can lead to use of alcohol as a coping
strategy).
Occupational effects
Repeated absenteeism, especially around weekends.
Impaired work performance and accidents.
Employment difficulties.
Effects on mental health
Anxiety and panic disorders.
Depressive illness.
Amnesia, memory disorders and dementia.
Treatment resistance in other psychiatric illnesses and as a factor in
relapse.
Self-harm.
Effects on physical health
Accidents/injuries.
Gastrointestinal system, including dyspepsia (indigestion), gastritis
and pancreatitis.
Various liver abnormalities.
Cardiovascular system, including cardiac arrhythmias, hypertension
and stroke.
Reproductive system, including impotence, problems with libido and
unexplained infertility.
Cancers of the mouth, pharynx, larynx, oesophagus, breast and
colon.
Other effects, including seizures, gout and eczema.
Confidence, based on a sound knowledge of when and how to ask a
patient/client about alcohol, is key to delivering brief advice about alcohol.
Such knowledge must encompass what conditions and issues can be
affected by, or caused by, alcohol consumption (see above), and the way
Date: 26 July 2010
Version: 0f
Page: 14 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
in which alcohol affects these conditions. Practitioners must keep their
knowledge of this subject up to date.
Thinking through the words to use comfortably and in a natural way, is an
important preparatory step for the practitioner.
13
Taking the first step: raising the issue of
alcohol
Brief advice is generally initiated in one of three ways:
Figure 3. Raising the issue of alcohol
Date: 26 July 2010
Version: 0f
Page: 15 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
14
Alcohol brief advice – the vital ingredients
14.1
Rapport and empathy
A good rapport is essential if a patient/ client is to feel able to have an
open and honest conversation about their alcohol consumption. The
practitioner providing the advice must have good listening skills and be
able to demonstrate empathy with and understanding of the individual’s
circumstances.
The acronym OARS can help practitioners to remember the key listening
skills29:
• Open-ended questions: allowing the patient to talk about issues
from their own point of view.
• Affirming: statements of appreciation and understanding.
• Reflective listening: allowing the practitioner to check his or her
understanding of what the individual has said.
• Summaries: bringing together the key points that the patient has
mentioned.
Together with empathy, it is important that the practitioner adopts a nonjudgemental approach and a neutral tone, for example, ensuring not to
register shock or surprise at what the patient/ client reveals.
14.2
Personal responsibility
Intervention through brief advice is distinguished by the underlying
principle that the patient/ client is best placed to know their own
circumstances and concerns, and therefore to decide what is best for them
at any given time. When a brief advice session is going well, the
conversation with the patient should feel like ‘dancing, not wrestling’24.
Confrontation has no place in the provision of brief advice; the emphasis is
on the individual’s freedom to make choices and the practitioner’s role in
providing information to inform those decisions in an objective fashion.
The practitioner should encourage the patient to take ownership of any
decision to change their behaviour by challenging any statements the
person makes which imply that they do not have a choice.
Date: 26 July 2010
Version: 0f
Page: 16 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
An example is illustrated in Figure 4 below:
Figure 4. Demonstrating Brief Advice
15
Screening/identifcation tools
15.1
Knowing who will benefit from brief advice
Alcohol brief advice is suitable for hazardous drinkers, but there is no
evidence that such an approach is effective for dependent drinkers. This
raises the issue of how to categorise people’s drinking behaviour.
To identify those who might benefit from brief advice, the practitioner
must ask the patient/ client a set of questions about their drinking, to
enable the practitioner to make an objective assessment of their level of
Date: 26 July 2010
Version: 0f
Page: 17 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
risk of alcohol. This is usually referred to as screening or increasingly as
identification. This permits the objective assessment of the person’s level
of risk without the introduction of stereotypes or other assumptions.
A formal screening tool (questionnaire) may not be necessary if a patient
tells the practitioner that they are drinking above recommended limits.
The action of using a screening tool can have benefits however, in respect
of providing an objective assessment and in some cases of motivating the
individual to change. In addition, the rigour of a screening tool may be
essential to monitoring and evaluation of a programme of delivering brief
advice.
15.2
Alcohol Screening Tools Available
Many different tools have been tested and found to accurately identify
hazardous and harmful alcohol users in healthcare settings.
15.2.1 Primary Care, Health Checks and A&E settings
AUDIT (Alcohol Use Disorders Identification Test) is regarded as the gold
standard, but as it contains 10 questions, so may be impracticable for
busy settings. The AUDIT tool is also an effective method for detecting
hazardous and harmful drinkers. Shortened versions of AUDIT have been
developed and used in practice.
The Fast Alcohol Screening Test (FAST) has a high level of accuracy in
detecting hazardous and harmful drinkers across a range of settings, and
contains only four questions13, 12. Moreover, many people who are
screened with the FAST tool only need to be asked one question in order
to obtain a positive result.
Although the FAST tool is not designed to detect alcohol dependence, if
any signs of dependence are evident, the practitioner could then use a
further screening tool to rule out dependence. Both the AUDIT and CAGE
tools can be used to identify dependence.
Manuals are available that describe the use of the FAST12 and AUDIT1 tools
in more detail.
15.2.2 Antenatal settings
Current guidelines recommend that pregnant women should avoid alcohol
altogether,9 and a formal screening tool is therefore not necessary in
antenatal settings. Simply asking pregnant women the following initial
screening question: ‘Are you drinking alcohol at all at the moment?’ leads
to the next step if the answer is “Yes”, which would be to obtain a clear
picture of how much and how often she is drinking, and to consider
whether more in-depth support is required to help her to cut down.
Date: 26 July 2010
Version: 0f
Page: 18 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
Practitioners may encounter a range of other screening tools for detecting
hazardous and harmful drinking and a guide to a range of screening tools
has been produced by the Primary Care Alcohol Information Service24.
16
Delivery of brief advice
The practitioner can judge how to approach the next stage of giving brief
advice by listening to the reaction of the patient on hearing the result of
the screening questionnaire.
Options at this point include:
• delivering brief advice if the patient/ client is receptive
•
ending the conversation at this stage, leaving the door open for a
further discussion in the future.22
Table 1. Approach to delivering brief advice
Patient response
Brief advice approach
‘No, I’m not interested.’
Exit strategy, but ensure that the
person knows where they can obtain
further information in the future.
‘What do you mean?’
Information
(individualised):
and
advice
Focus on the benefits of cutting down,
and the risks linked to alcohol.
Discuss drinking limits.
‘I don’t think I drink too much.’
Enhance motivation.
‘I think I could make some changes. Menu of options that would lead to a
What could I do?’
reduction in risk (individualised).
Date: 26 July 2010
Version: 0f
Page: 19 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
‘I think it would be really hard to cut Build confidence.
down.’
‘I have been trying to cut down, but Coping strategies (individualised).
sometimes it’s not easy.’
17
Summary of the five alcohol brief
approaches
17.1
Information and advice (with permission)
If the patient is receptive to advice, the practitioner should take the
opportunity to provide accurate information about how to reduce the
harmful effects of drinking, and about the benefits of cutting down. The
more relevant the information is to the person’s particular situation, the
more valuable this approach will be. This approach may be sufficient for
some patients to decide to cut down, and if they know how to go about
this and are not looking for any further help, the brief intervention could
end here.
17.2
Enhancing motivation
If the patient is in two minds about changing their drinking habits, it might
be useful for the practitioner to help them explore the situation further
and to weigh up the advantages and disadvantages of their current
drinking habits against the advantages and disadvantages of changing
their drinking behaviour. The practitioner adopts a neutral approach but
reinforces any comments made by the patient which acknowledges harm
or risk which might be caused by their current drinking habits. This
technique uses a tool called the motivation matrix28 .
17.3
Menu of options
Some patients may wish to cut down their drinking, but are unfamiliar
with the concept of units of alcohol, and may be unaware of the fact that
small changes to their drinking behaviour can dramatically reduce the risk
of potentially harmful effects associated with alcohol consumption. In this
situation, the practitioner will ideally support the person in identifying
ways to reduce the risks associated with their drinking. This can lead to
negotiation with the patient with regard to the specific goals that they
Date: 26 July 2010
Version: 0f
Page: 20 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
would like to set for changing their drinking behaviour, based on their
individual needs and circumstances.
17.4
Building confidence
A person is more likely to change their behaviour if they have confidence
in their ability to change. The practitioner can help the patient to increase
their confidence in three ways:
1. by reminding them of occasions in the past when they have been
successful in making changes
2. by looking at role models (i.e. other people in a similar situation who
have succeeded in making changes)
3. by highlighting the fact that significant individuals in the person’s life
(including the practitioner) have belief in his or her ability to
change.
This approach also uses a tool called the ‘Readiness Ruler.’ 6
17.5
Coping strategies
It is particularly helpful to ask the patient to identify any especially
stressful events or circumstances that might trigger a return to their
previous drinking patterns, and to discuss these situations with them. This
enables the individual to avoid potential triggers and high-risk situations,
and to develop appropriate coping strategies and support networks that
will enable them to resist pressure to return to their previous drinking
patterns, and to get back on track if they do have a lapse.
18
Appropriate referral to another service or
professional
A practitioner may wish to consider referring a patient to another service
if:
• the individual wants to speak to someone else or might benefit from
additional help or support
• discussion with the individual indicates signs of alcohol dependence
or they have screened positively for dependence
• the individual has any problems that the practitioner cannot
adequately support or address (e.g. other substance use or mental
or physical health problems)
• there is a concern about child protection.
In addition, the practitioner may wish to refer a patient to a source of
additional information on alcohol.
Date: 26 July 2010
Version: 0f
Page: 21 of 28
Public Health Wales
19
Briefing Paper Delivering Alcohol Brief
Advice
Summary
The delivery of brief advice is much more than a conversation in which the
topic of alcohol is mentioned. It is an interaction that is structured by the
practitioner and which aims to help the patient to consider their drinking
and its consequences in a way that supports and encourages change. Brief
advice is based on evidence of what approaches are effective, and
practitioners are likely to benefit from training to develop the skills and
techniques for delivering brief advice in practice. The next section
Frequently asked questions, includes further information on the training
that is available in Wales.
20
Frequently asked questions
20.1
Common concerns about providing brief advice in
practice
Most of the people I help don’t want to change their drinking
pattern. How do I know that this will really work?
There is strong evidence that providing an intervention through brief
advice (particularly in a primary care and A & E settings25) can be very
effective. Alcohol consumption can be reduced for periods of a year or
more among people who are drinking more than the recommended
drinking limits, but who are not dependent upon alcohol.18,25,29, 1
Although relatively modest , at a reduction of 15–35% in consumption
levels, positive health and social benefits are that are significant both for
the individual and, if many people make small changes, for society as a
whole.29
Like any health intervention, brief advice does not work for
everybody, but such advice is often rated as the single most effective
intervention
for reducing alcohol consumption, comparing extremely
favourably with many other health interventions in terms of effectiveness
and cost-effectiveness.29 It has been calculated that one in every eight
patients who receive brief advice delivered in the recognised manner is
likely to benefit in terms of reduced health risks, compared with one in
every 20 people who receive brief advice to stop smoking.29
If a client does not want to discuss their drinking, that is their right. It is
preferable for the practitioner to end the conversation about alcohol but to
‘leave the door open’ for further discussion at a later date. In most cases
it would also be helpful for the practitioner to offer the client some written
information and guidance in the form of a leaflet, including details of
where to seek advice should they decide that they need help in the future.
What if people don’t want to change their drinking?
Date: 26 July 2010
Version: 0f
Page: 22 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
Central to the delivery of brief advice is the patient’s/ client’s right to
choose not to act on that advice. The practitioner must recognise that a
person’s motivation to change is not fixed, and that the techniques
employed in delivering brief advice can increase a person’s willingness to
change. The practitioner can always ‘leave the door open’ for further
discussion at a later date. If the client is unwilling to discuss the matter
further, it is important that the practitioner respects this and does not try
to force the issue.
How do I raise the Issue of drinking too much without offending
someone?
It may be surprising but the evidence suggests that people are not
offended by professionals asking them about their drinking habits. This
has been endorsed by recent market research conducted in Wales3.
Research indicates that people are co-operative and appreciative when
professionals take an interest in their health25. If a practitioner asks a
patient about their drinking, it is done in the context of exploring if cutting
down on alcohol will help them deal with any health and/or social issues
that they may have. This is done in a non-confrontational and supportive
manner that provides the individual with the assurance and
encouragement that they may need in order to reflect on their alcohol use
and modify their drinking behaviour if necessary.
The brief advice approach is not compatible with telling someone that they
drink “too much”. A basic principle of brief advice is that the individual is
the expert on what is right for them, and that the responsibility for change
lies with that individual. The philosophy of brief advice is that it is up to
the individual to decide what level of alcohol consumption is ‘too much’ for
them. Consistent with decisions regarding other lifestyle issues, such as
diet and exercise, people make choices based upon the level of risk with
which they are comfortable.
Making a comparison with smoking, most people who smoke are aware of
the risks, whilst many people who are drinking more than the
recommended drinking limits will not necessarily be aware that they are
putting their health at risk. Brief advice ensures awareness of the risks
and a balancing of those risks with the perceived benefits from their
current drinking patterns. Acting on this information is the responsibility
of the individual, with the practitioner in a supportive role if desired.
20.2
Questions about current drinking limits
Are the drinking limits set too low?
The current recommendations are that men should drink no more than
three – four units of alcohol per day, and no more than 21 units per week,
and that women should drink no more than two – three units of alcohol
Date: 26 July 2010
Version: 0f
Page: 23 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
per day, and no more than 14 units per week. All drinkers should have at
least two alcohol-free days per week.
Although these limits may appear to be low compared with what many
people drink in Wales, they are based upon medical and scientific evidence
of the short and long term effects of alcohol. The UK Department of Health
has set the recommended limits at the level that the best evidence
suggests carries minimal risk of harm.
The evidence indicates that drinking in excess of these limits progressively
increases the risk of damage to health. This means that any increase in
consumption above the recommended drinking limits increases a person’s
risk of alcohol-related health problems. Conversely, however, any
reduction in drinking will reduce the risks, so even if a person does not
feel that they can reduce their alcohol consumption to below
recommended limits immediately, they will still benefit from reducing their
drinking by even a small amount.
Given the large number of people who report drinking more than the
recommended daily limits, those practitioners delivering brief advice may
well themselves examine their own personal lifestyle and behaviour
choices when working with and supporting people to improve their health.
However, the practitioner who finds that they sometimes drink more than
the recommended drinking limit should not feel unable to deliver brief
advice provided they are aware of this fact and adopt an objective
approach to discussing alcohol with patients/ clients. It is not usually
appropriate or necessary for you to disclose or discuss your own personal
lifestyle choices or drinking habits when delivering brief advice.
What about weekly drinking limits?
Weekly limits are not used in current guidance. The guidance on safer
levels of alcohol consumption was changed from weekly to daily limits in
1995,3 but it has taken a long time for this information to be fully
understood by the public. There is still widespread lack of awareness of,
and confusion about, the limits. This confusion is reflected in the findings
of market research conducted on behalf of the Welsh Assembly
Government8.
What about the reported benefits of alcohol- are they true?
The simple message is that there is no benefit in drinking more alcohol
than the daily limits for any age group.
It is not considered appropriate to advise people who currently do not
drink alcohol to begin to do so, or for those who drink occasionally to
increase their alcohol consumption.
Date: 26 July 2010
Version: 0f
Page: 24 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
Some evidence exists that for men over 40 years and postmenopausal
women, there is some beneficial effect of moderate alcohol consumption,
mainly the protective effects against coronary heart disease obtained from
drinking no more than one or two units of alcohol per day. This protective
effect can be obtained from any form of alcohol, including wine, beer and
spirits.
21
What training will I need to deliver brief
advice?
The training that is required by an individual practitioner in order to
deliver brief advice will depend on their previous training and practice, and
their current level of skill, knowledge and understanding. The Welsh
Assembly Government is funding a programme of alcohol brief advice
training which is designed to enable practitioners to competently,
confidently and appropriately raise and respond to alcohol-related issues
with their patients/ clients, and to deliver brief advice in line with existing
evidence.
The training is suitable for practitioners who have varying levels of
knowledge about alcohol and brief advice skills, and includes the following
elements:










Understanding what brief advice is, the evidence base and policy
background.
Examining the attitudes of the practitioner and others to alcohol,
and how those attitudes impact on practice.
Exploring the obstacles to the implementation of brief advice by
practitioners, and how these barriers and concerns can be resolved.
Recognising good practice and the key skills involved in effectively
delivering brief advice.
Understanding current units and drinking limits, and the various
terms commonly used to describe people’s relationship with alcohol.
Being comfortable with the wording that can be used when raising
the issue of alcohol with clients, and the health and social problems
to which alcohol can be a contributory factor.
Utilising screening tools to accurately assess the health risks
associated with a person’s drinking, and giving appropriate
feedback.
Developing key skills for, and confidence in, delivering each of the
five brief advice approaches outlined in paper and in delivering a
complete brief advice from start to finish.
Being able to observe and critique the delivery of a brief advice by
oneself and others.
Review and evaluation of one’s readiness to deliver brief advice,
including any further support that is needed.
Date: 26 July 2010
Version: 0f
Page: 25 of 28
Public Health Wales
22
Further reading
22.1
Screening
Briefing Paper Delivering Alcohol Brief
Advice
• Manual for FAST;
www.aerc.org.uk/documents/pdfs/FinalReports/AERC_FinalReport_0
007.pdf
• Manual for AUDIT;
whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf
• Guide to screening tools;
www.alcoholconcern.org.uk/files/20030910_143338_Screening%20f
actsheet%20final%20for%20web%202.pdf
22.2
Brief Interventions/Advice
• National Treatment Agency for Substance Misuse (2006).
Assessment and measuring treatment outcomes. In: Review of the
Effectiveness of Treatment for Alcohol Problems;
www.nta.nhs.uk/publications/documents/nta_review_of_the_effectiv
eness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2
.pdf
• Scottish Health Action on Alcohol Problems (SHAAP). Guide to Brief
Advices; www.work-interactivetest.co.uk/UserFiles/File/Screening%20and%20brief%20intervention
s.pdf
23
References
1. Babor and Grant (Eds) (1992). Project on the Identification and
Management of Alcohol-Related Problems. Report on Phase II: A
randomised clinical trail of brief interventions in the primary health
care setting. World Health Organization, Geneva.
2. Ballensteros et al. (2004). Efficiency of brief interventions for
hazardous drinkers in primary care: systematic review and metaanalysis. Alcoholism: Clinical and Experimental Research, 28, 608618.
3. Beaufort Research for National Public Health Service Alcohol
Intervention Study. Research Report 2009, Cardiff
4. Bertholet et al. (2005). Brief alcohol intervention in primary care:
systematic review and meta-analysis. Archives of Internal Medicine,
165, 986-995.
5. Catto S, Gibbs D (2008). How Much Are People in Scotland Really
Drinking? A Review of Data from Scotland’s Routine National
Surveys. NHS Health Scotland, Glasgow.
6. COLES E, PATES R. for WELSH ASSEMBLY GOVERNMENT. The
Economic and Social Costs of Class A drug and alcohol abuse in
Date: 26 July 2010
Version: 0f
Page: 26 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
Wales. Cardiff: Welsh Assembly Government (Unpublished).
7. Cuijpers et al. (2004). The effects on mortality of brief interventions
for problems drinking: a meta-analysis. Addiction, 99, 839-845.
8. Department of Health (1995). Sensible Drinking: the Report of an
Inter-Departmental Working Group. Department of Health, London.
9. Department of Health (2007). Updated Guidance on Alcohol
Consumption in Pregnancy. Department of Health, London.
www.tin.nhs.uk/sys_upl/templates/PT_Directory_RSS/PT_Directory
_RSS_details.asp?id=102152&pgid=2470&tid=163
10. Fitzgerald (2008). Common definitions and terminology for use in
health behaviour change and related training for NHS Health
Scotland – agreed terms. Unpublished paper.
11. GILMORE I and SHERON N. (2007) Reducing the harms of alcohol in
the UK. British Medical Journal, 2007, 335: pp 1271 – 1272
12. Health Development Agency and the University of Wales College of
Medicine (2002). Manual for the Fast Alcohol Screening Test
(FAST). Fast screening for alcohol problems. Health Development
Agency, London.
13. Hodgson et al. (2002). The Fast Alcohol Screening Test. Alcohol and
Alcoholism, 27, 61-66.
14. HOME OFFICE. Crime in England and Wales 2006/07. London:
Home Office, 2007
15. HOME OFFICE. Young People and Crime: Findings from the 2005
Offending, Crime and Justice Survey Home Office Statistical Bulletin
17/06. London: Home Office, 2006.
16. HOME OFFICE. Statistical Bulletin, Crime in England and Wales
2006/07. London: Home Office, 2007.
17. HM Government. Safe Sensible Social. The next steps in the
national Alcohol Strategy. London: HM Government, 2007.
18. Kaner et al. (2007). Effectiveness of Brief Alcohol Interventions in
Primary Care Populations (Cochrane Review). John Wiley & Sons,
Chichester.
19. Moyer et al. (2002). Brief interventions for alcohol problems: a
meta-analytic review of controlled investigations in treatmentseeking and non-treatment-seeking populations. Addiction, 97,
279-292.
20. National Public Health Service, 2009, Scoping a Community-based
Screening and Brief Interventions Service for Hazardous Drinkers
21. NATIONAL PUBLIC HELATH SERVICE FOR WALES. Alcohol and
health in Wales: A major publish health issue. Cardiff: National
Public Health Service for Wales, 2006.
22. NHS Health Scotland (2009). Alcohol Brief Interventions Training
Manual. NHS Health Scotland, Edinburgh.
23. Poikolainen (1999). Effectiveness of brief interventions to reduce
alcohol intake in primary health care populations: a meta-analysis.
Preventive Medicine, 28, 503-509.
24. Primary Care Alcohol Information Service 92001). Factsheet:
Date: 26 July 2010
Version: 0f
Page: 27 of 28
Public Health Wales
Briefing Paper Delivering Alcohol Brief
Advice
Screening Tools for Healthcare Settings. Alcohol Concern, London.
25. Raistrick et al. (2006). Review of the Effectiveness of Treatment for
Alcohol Problems. National Treatment Agency for Substance Misuse,
London.
26. Rolnick, S. Miller, W. R., and Butler, C.C. (2008) Motivational
Interviewing in Healthcare. The Guildford Press, London.
27. Rollnick et al. (1999). Health Behaviour Change: a Guide for
Practitioners. Churchill Livingstone, Edinburgh.
28. Scottish Health Action on Alcohol Problems (2007). Alcohol and
Health Factsheet. Scottish Health Action on Alcohol Problems,
Edinburgh.
29. Scottish Intercollegiate Guidelines Network (2003). Guideline 74.
The Management of Harmful Drinking and Alcohol Dependence in
Primary Care. Scottish Intercollegiate Guidelines Network,
Edinburgh.
30. A profile of Alcohol and Health in Wales, Wales Centre for
Health/NPHS, 2009
31. WELSH ASSEMBLY GOVERNMENT, Welsh Health Survey 2005-06.
Cardiff: Welsh Assembly Government, 2007.
32. WELSH ASSEMBLY GOVERNMENT, 2008 ‘Working Together to
Reduce Harm’ The Substance Misuse Strategy for Wales 2008 –
2018
33. World Health Organization. International statistical classification of
diseases and related health problems. 10th ed. Geneva: The
Organization; 1992.
Date: 26 July 2010
Version: 0f
Page: 28 of 28