Brief interventions for unhealthy alcohol and other substance use in adults

INTRODUCTION — 

Brief interventions refer to preventive counseling aimed at decreasing unhealthy alcohol or other substance use. Unhealthy alcohol use is defined as the spectrum of use that can result in health consequences and includes risky use and alcohol use disorders. Alcohol and other substance use contributes to extensive disability and death [1-5]. Alcohol and other substance use cause harm to individuals with risky use in addition to those with substance use disorders. (See "Screening for unhealthy use of alcohol and other drugs in primary care" and "Risky drinking and alcohol use disorder: Epidemiology, clinical features, adverse consequences, screening, and assessment".)

Brief interventions were originally developed to address unhealthy alcohol use in public health and general medical settings. The term “brief” was used to distinguish these preventive or “early” interventions by nonspecialists from intensive specialty alcohol treatment.

Brief interventions are used in diverse settings (eg, primary care, pediatrics, emergency care, inpatient), and in different populations (adults and youth, pregnant people, alcohol-related medical conditions) and have been adapted to online interventions. Brief interventions have also been tested in the treatment of other unhealthy substance use (eg, cannabis, opioids, stimulants).

This topic provides an overview of brief interventions for unhealthy alcohol and other substance use. Topics discussing screening for alcohol and other substance use and diagnosis and treatment of alcohol and other substance use disorders are found elsewhere.

●(See "Screening for unhealthy use of alcohol and other drugs in primary care".)

●(See "Alcohol use disorder: Treatment overview".)

●(See "Stimulant use disorder: Treatment overview".)

●(See "Opioid use disorder: Treatment overview".)

●(See "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment".)

BRIEF INTERVENTION FOR ALCOHOL USE — 

The goal of brief intervention for alcohol use is to decrease unhealthy alcohol use and prevent the adverse consequences of alcohol on health, function, and well-being, generally, in individuals without alcohol use disorder. (See 'Who we treat' below.)

Who we treat — We suggest brief interventions for all individuals (including pregnant individuals) in primary care settings who screen positive for unhealthy alcohol use but do not have alcohol use disorder. This is supported by randomized trials and meta-analyses and is consistent with the US Preventive Services Task Force recommendation statement [6-34].

For all individuals with high-risk drinking (ie, positive screen for unhealthy alcohol use) our first step is to assess for alcohol use disorder. We do this using the Alcohol Symptom Checklist. Patients with an alcohol use disorder typically require more support than a brief intervention to change their drinking [35-39]. Assessment for alcohol use disorder in an individual with unhealthy alcohol use is discussed elsewhere. (See "Screening for unhealthy use of alcohol and other drugs in primary care", section on 'Brief assessment strategies'.)

For those who screen positive and have an alcohol use disorder, we favor standard therapy discussed elsewhere. Brief interventions are not intended as treatment for patients with alcohol use disorders [18]. However, in patients with alcohol use disorder who will not accept therapy, we use brief interventions as well [40-45]. (See "Alcohol use disorder: Treatment overview".)

Brief interventions have demonstrated efficacy for adults with unhealthy alcohol use across many different settings [6-8,18-29]. The strongest evidence of efficacy of brief interventions is in primary care settings [9,18,19,30]. (See 'Primary care settings' below.)

The US Preventive Services Task force has examined brief interventions across diverse settings and populations, and with varied methods. In a review of brief interventions (68 studies, n = 36,528) including in-person, telephone and digital (with or without human contact) in primary care, military recruitment centers, sexual health clinics, psychology classes, university health centers, and the general population (excluding emergency department, hospital, and mental health or addiction clinics), brief interventions, as compared to control led to [6]:

●A decline in number of drinks per week after 6 to 12 months (32 trials, n = 15974; weighted mean difference -1.6, 95% CI -2.2 to -1.0)

●Fewer people exceeding recommended drinking limits over 6 to 12 months (15 trials, n = 9760; odds ratio 0.6, 95% CI 0.5-0.7)

●Fewer reporting episodes of heavy drinking (12 trials, n = 8108; odds ratio 0.7, 95% CI 0.6-0.8)

The number needed to treat to achieve drinking within recommended limits was found to be 7.2 (95% CI 6.2-11.5).

Furthermore, trials with the largest impact on drinking were those with the highest levels of baseline alcohol use [6,18,20]. Several of the trials including patients with the heaviest drinking (excluding those with alcohol use disorders) found that brief interventions were associated with improvements in health outcomes [24,31,32].

Most [20,33,34], but not all [46], meta-analyses that have evaluated brief interventions across sex report that females and males benefit equally from brief alcohol intervention. Little is known about the effectiveness of brief interventions for people of different race, ethnicity, or place of residence (eg, rural versus urban) [33,47].

Implementation

Duration, content, and style — Brief interventions generally include one or two sessions typically lasting from 5 to 20 minutes [18,19,48]. Initial brief interventions are offered when unhealthy alcohol use is identified by screening during routine care, although follow-up visits might be scheduled to specifically address unhealthy alcohol use depending on severity and patient willingness. The effectiveness of brief intervention does not appear to depend on the duration of the intervention [19]; however, interventions with multiple contacts appear to be particularly effective [6].

Effective brief interventions fall on a spectrum from patient-centered advice to brief motivational counseling. Most brief interventions studied in trials have blended these two elements [49]:

●Brief interventions based on counseling – These brief interventions are typically focused on increasing motivation to change, self-efficacy, and offering patient-centered care that overcomes the stigma often associated with unhealthy use of alcohol. Brief interventions based on counseling are typically offered by integrated mental health clinicians (eg, social workers, psychologist, nurse, other counselors) who are trained to manage unhealthy use of alcohol or digital interventions providing similar components, especially normative feedback (ie, feedback designed to correct misperceptions regarding the prevalence of heavy drinking). (See "Substance use disorders: Motivational interviewing" and "Alcohol use disorder: Psychosocial management".)

●Advice-based brief interventions – These interventions are often offered by physicians or other general medical providers. Advice-based brief interventions [18], interventions by nurses [50], and those with multiple contacts [6], appear to be most effective. Opportunistic, brief patient-centered advice about drinking can be easily integrated into medical care and may be more effective than brief interventions based on counseling; indirect comparisons have reported that advice-based brief intervention may lead to greater improvement on measures of alcohol consumption as compared to placebo, than counseling based intervention [18].

Due to the stigma of alcohol use disorder, patients may be sensitive to being told they have a “positive” alcohol screen. Stigmatization may occur when there is an assumption or implication that a patient caused their disease and can control it. To minimize this stigma, we use language that is not stigmatizing and normalizes screening and brief intervention by making them part of our focus on overall health (table 1).

Components — The components of a brief interventions vary, but brief interventions each typically include components of the acronym “FRAMES” [21]. FRAMES is an acronym for:

●Feedback linking alcohol use to health – Feedback includes expressing concern that drinking at the level the patient has reported could worsen their health and offering information on the associations between alcohol use and health. We help patients see the link between their alcohol use and concerns or issues that the patient may be experiencing (eg, elevated blood pressure, depression, sleep problems, elevated liver enzymes, gastroesophageal reflux) or alcohol-related risks that they are concerned about (eg, breast or prostate cancer, stroke, weight gain) or management of their chronic health conditions [51-54]. (See "Risky drinking and alcohol use disorder: Epidemiology, clinical features, adverse consequences, screening, and assessment", section on 'Adverse consequences'.)

●Responsibility – Brief interventions emphasize patient autonomy. Patients are responsible for deciding if they want to make a change. When we offer brief interventions, we offer medical advice, but elicit patients’ perspectives and support their autonomy in making a decision about what they want to do. We make every effort to make it clear that the decision is up to them and that we as their medical team are available to provide information and advice.

●Advice – An important part of brief interventions is to discuss recommended drinking limits and provide written information (eg, handout or visit summary) explicitly stating recommended limits and standard drink sizes.

For some patients, no alcohol use is recommended (eg, pregnant or planning to become pregnant, patients with liver disease or heart failure), and research publicized by the World Health Organization indicates there may be no safe level of alcohol use [55,56].

However, many people choose to drink alcohol. For those individuals, we suggest they drink as little as possible. National Institute on Alcohol Abuse and Alcoholism and the United States Department of Agriculture guidelines recommend one drink or less in a day for women and two or less for men [57].

When offering brief interventions we recommend against any heavy drinking (also called risky drinking) defined as [57]:

•For women or men 65 years of age or older: more than one standard-sized drink a day on average (seven drinks a week) or more than three drinks on any day.

•For men less than 65 years of age: more than two standard-sized drinks a day on average (14 drinks a week) or more than four drinks on any day.

In the United States, standard-sized drinks are defined as 14 grams of absolute ethanol: 12 oz of regular beer, 5 oz of wine, or 1.5 oz of 80 proof spirits.

Reasons for lower limits for heavy or risky drinking in women than men relate to evidence of increased risk of death and cirrhosis at lower levels of drinking in women than men, and the risk of breast cancer increases at less than one drink daily on average for women. The reason for lower limits for men age 65 and older is that capacity to metabolize alcohol decreases as people age [58-60].

●Menu of options for cutting down or stopping – We discuss strategies for decreasing drinking. They depend on a patient’s goals, values, and preferences, prior efforts at change, and the level of symptoms (table 2). Examples of strategies we encourage depending on the clinical scenario include:

•Changes in the environment – Examples include not having alcohol in the home, not going places or spending time with friends that lead to heavy drinking, and adding new hobbies or social activities that do not include drinking [61].

•Decreasing the amount of alcohol consumed per occasion – This can be done by alternating alcohol and nonalcohol-containing drinks, setting a personal limit for the number of drinks per occasion, changing from double to single cocktails or beer with lower alcohol content, and eating before drinking or drinking slowly to decrease absorption of alcohol.

●Empathy – Empathy is expressed through inquiring about patients’ experiences, listening carefully, and reflecting what is heard.

Brief interventions include “open-ended” questions about the patient’s drinking and their reason for change (eg, “Can you tell me about how drinking alcohol fits into your life and how it has changed over time?” or “ What do you like most about drinking? What do you like least?”).

Listening carefully and reflecting on what is stated is central to brief interventions. Reflective listening can help patients feel understood and may lead to further disclosures. (See "Substance use disorders: Motivational interviewing".)

In addition to simple reflections and summarizing what has been heard, complex reflections can help highlight ambivalence which is often present if drinking has started to cause problems. As an example, a reflective response that validates the patient's concern about their drinking might be: “I hear that drinking is central to the time you spend with important friends and the fun you have on weekends. And I also hear that friends and families have made comments about concerns that you are drinking too much. It sounds like you have concerns too.”

●Self-efficacy – Helping patients feel confident about their ability to change and setting them up to experience success can build self-efficacy. As in all behavioral change counseling, supporting patients in making feasible, concrete steps toward change is most likely to lead to success. Small successes lead to subsequent successes. Helping patients set “SMART” goals (specific, measurable, achievable, relevant, and with a specified timeframe) can support their success. Eliciting or reflecting on prior successful behavior change(s) that a patient has achieved (eg, smoking, increased exercise, change in diet, etc) may increase self-efficacy and support change. Expressing optimism about patients’ ability to make changes for their health, also supports self-efficacy.

Examples addressing each of these components during a brief alcohol-related intervention for a patient with a positive alcohol screen are found below (FRAMES elements shown in bold):

●Feedback – “I am concerned that your drinking could be causing high blood pressure, as well as contributing to your depression and sleep problems.”

●Advice – “I know making changes can be hard, but cutting down could really help your depression and sleep, as well as your blood pressure. I advise you to drink no more than two drinks a day.”

●Responsibility – “What are your thoughts about this? Of course, the decision is up to you. Is it something you would consider?”

●Empathy – “It sounds like drinking is something you and your partner really enjoy together, but you are open to trying to limit yourself to two drinks on any day?”

●Self-efficacy – “Based on the amazing changes you made with diet and exercise, I am sure you can do it.”

●Menu of options – “I’ll include information on recommended limits as well as standard drink sizes and a list of strategies that help people cut down in your visit summary. I’d like to see you back to check your blood pressure in about a month and see how it’s going. Would that be okay with you?”

Follow-up — We follow up brief interventions to provide reinforcement and monitor progress towards the patient’s goal. Brief interventions by clinicians are most effective when they include multiple contacts [6,20]. Meta-analyses have supported the efficacy of multicontact brief interventions; these include follow-up appointments with the clinician or telephone calls from a medical team member [6,20]. Phone follow-up in one to two weeks is ideal but depending on patient preference and the clinical situation (eg, severity of unhealthy alcohol use), follow-up about alcohol use is often integrated with routine follow-up for other conditions in one to three months.

Adverse effects — No harms of brief intervention addressing alcohol use in adults, youth or pregnant women were found in the US Preventive Services Task Force reviews, although most trials did not report on harms [6].

Setting — Brief interventions for unhealthy alcohol use have been implemented in various clinical settings.

Primary care settings — The strongest evidence of efficacy of brief alcohol intervention is in primary care settings [9,18,19,30]. Multiple meta-analyses have supported brief intervention in this setting [6,18,20,33]. We recommend offering brief interventions for all patients in primary care settings (including pregnant individuals) who screen positive for unhealthy alcohol use.

Brief interventions have been ranked one of the highest prevention priorities for primary care. Based on the burden of alcohol-related morbidity and mortality and the relatively low cost of brief interventions, the National Commission on Prevention Priorities ranked alcohol screening and brief counseling the second highest prevention priority for United States adults in primary care, ahead of all prevention activities except tobacco screening and counseling [62].

Studies supporting brief intervention in primary care settings include:

●In a review of trials focusing on primary care populations (24 trials; n = 8811 participants) treatment with brief intervention, as compared with control, led to a reduction in ethanol intake of 26 (95% CI -37 to -14) grams/week approximately equivalent to two standard drinks [18].

●The US Preventive Services Task Force review examined brief interventions offered in various settings [6]. When restricted to studies in primary care settings offered by a primary care team (16 trials), brief interventions led to a reduction of 2.8 drinks per week (95% CI -4.1 to -1.5).

Emergency settings — We offer brief interventions to patients who screen positive for unhealthy alcohol use in emergency care settings as part of high-quality clinical care whenever possible.

While some meta-analyses show efficacy of brief intervention for unhealthy alcohol use in emergency settings, the effects appear to be smaller than those in primary care settings [18,63]. For example, in the meta-analysis above that showed a decrease of 26 (95% CI -37 to -14) grams of ethanol a week in primary care, the decrease in emergency care settings (10 trials, n = 6386) was 9.7 (95% CI -17.5 to -1.9) [18].

Other meta-analyses and reviews have not found benefit of brief intervention in emergency settings [33,50]. While it has been postulated that patients with unhealthy alcohol use who seek care in emergency settings due to injuries, would be more likely to respond to brief intervention due to a hypothesized teachable moment, evidence on the effectiveness of brief intervention in injured patients is also mixed [64-72]. Brief intervention may be most effective in injured patients who receive advice [68], drink more [69], and attribute their injuries to alcohol use [70].

The potential small benefits observed in some trials and meta-analyses, the lack of any documented harms of brief interventions in this setting, and the potential that alcohol-related advice from professionals can contribute to decisions to change and underlie our suggestion to add brief interventions to emergency settings [73].

Hospitalized patients — We recommend offering inpatients who screen positive for unhealthy alcohol use brief alcohol interventions for the same reasons as patients in emergency department above, although the effectiveness of brief alcohol intervention over the subsequent 12 months in hospitalized patients is uncertain.

For example, a meta-analysis of 14 trials (n = 4041) reported that in individuals hospitalized for reasons other than alcohol treatment, brief intervention (up to three sessions) as compared with control condition, led to greater reduction in ethanol consumption (in grams/week) at six- and nine-month follow-up (-69.4, 95% CI -128.1 to -11.7 and -182.9, 95% CI -360 to -5.8, respectively). However, at one-year follow-up, the effects between treatment groups was similar (-33.6, 95% CI -82.3 to 15.0) [74]. Other trials have shown conflicting results [75-83].

Of note, the generally negative results of brief interventions in hospitalized populations may reflect the high rate of moderate-severe alcohol use disorder in some samples of hospitalized patients. Brief interventions have not been shown to be effective in patients with alcohol use disorder, even when brief interventions are extended with up to six sessions [84-86].

Digital brief interventions — Digital brief interventions (eg, web-based interventions) are effective for decreasing alcohol consumption in diverse adult populations recruited in primary care, workplaces, emergency departments, universities, and communities [6,8,87-93]. Most digital brief interventions are completed outside medical settings (eg, at home) and beneficial effects are relatively small in systematic reviews and meta-analyses [88,89,91-94].

Comparisons between digital brief interventions and other brief interventions have found contrasting results [6,8,88,91,92,94]. Indirect comparisons indicate that digital interventions appear to be less effective than practitioner delivered interventions, although the former have predominantly been tested in college students [6,94].

Results of multiple reviews suggest that newer studies, which include younger populations, have smaller effects and that trials of older people had greater effects (potentially because they drank more at baseline) [6,8,18,88].

Evidence from indirect comparisons suggests that smartphone apps may be more effective than text messaging interventions for decreasing excessive drinking:

●Two trials of smartphone apps, one in adults in the United Kingdom and one in college students in Switzerland, showed decreased alcohol consumption with digital app use as compared with a webpage with alcohol-related advice or “thank you” webpage with access to equivalent incentives [87,95].

●A systematic review found limited evidence to support the efficacy of brief interventions based on texting [96].

BRIEF INTERVENTION FOR OTHER SUBSTANCE USE — 

Brief interventions for unhealthy use of other substances do not appear to decrease substance use in patients who screen positive for unhealthy use based on a review conducted for the US Preventive Services Task Force and others [33,97-108]. For all individuals whose screening indicates unhealthy nonalcohol substance use, we recommend an assessment for substance use disorder using the Substance Use Symptom Checklist for nonalcohol substance use [38,109].

There are many potential reasons that brief interventions may be effective for unhealthy alcohol use but have not been shown to be effective for other substance use. Heterogeneity of interventions and samples studied, including severity of substance use disorder, legal implications of substance use and differences in research methods limit meta analyses [18,97,102,103,105,110-112].

A meta-analysis investigating the efficacy of brief intervention for drug use found that brief intervention as compared with usual care led to similar frequence of use at four- to eight-month follow-up (standardized mean difference -0.07, 95% CI -0.17 to 0.02) [105]. However, two trials have reported a small beneficial effect of brief intervention for drug use implemented in emergency departments [106,107].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Opioid use disorder and withdrawal" and "Society guideline links: Benzodiazepine use disorder and withdrawal" and "Society guideline links: Alcohol use disorders and withdrawal" and "Society guideline links: Stimulant use disorder and withdrawal" and "Society guideline links: Cannabis use disorder and withdrawal".)

SUMMARY AND RECOMMENDATIONS

●Brief interventions – Brief interventions refer to preventive counseling aimed at decreasing unhealthy alcohol use to prevent the adverse consequences on health, function, and well-being. (See 'Introduction' above.)

●Implementing a brief intervention – Brief intervention for unhealthy alcohol use generally includes one or two sessions typically lasting from 5 to 20 minutes or longer. Effective brief interventions fall on a spectrum from patient-centered advice to brief motivational counseling. Most brief interventions studied in trials have blended these two elements. (See 'Implementation' above.)

●Components – The content of brief alcohol intervention varies, but often includes the following components (see 'Components' above):

•Feedback – Express concern about the impact of drinking on the patient’s health and provide information linking alcohol use to specific health issues they care about

•Responsibility – Emphasize that the decision to change is up to the patient

•Advice – Advise to drink as little as possible and avoid heavy drinking, and provide a handout on limits and standard drink sizes

•Menu of options for cutting back – Discuss strategies for decreasing drinking (table 2)

•Empathy – Express empathy through careful listening and reflecting on what patients say

•Self-efficacy – Support patient success with optimism, reflecting their strengths, and encouraging feasible goals and concrete small steps

●Brief intervention for unhealthy alcohol use – For all individuals (including pregnant individuals) in the primary care setting, who screen positive for unhealthy alcohol use but do not meet criteria for alcohol use disorder, we suggest brief interventions rather than no specific intervention (Grade 2C). (See 'Setting' above.)

We also provide brief intervention to individuals with alcohol use disorder who do not accept referral for specialty treatment. (See 'Brief intervention for alcohol use' above and 'Primary care settings' above.)

As part of high-quality clinical care, we offer brief interventions, whenever possible in emergency settings, university health settings, and in hospitalized patients. (See 'Emergency settings' above and 'Hospitalized patients' above.)

●Brief intervention for other substance use – Brief interventions for use of other substances have not been shown to decrease substance use in patients who screen positive for unhealthy use. However, for all individuals whose screening indicates unhealthy nonalcohol substance use, we further assess for the presence of a substance use disorder and review treatment options. (See 'Brief intervention for other substance use' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Richard Saitz, MD, MPH, FACP, DFASAM, who contributed to earlier versions of this topic review.