At-risk drinkers can be effectively treated in primary care by using brief interventions (SAMHSA 2008). Patients with more severe alcohol use problems (as defined by DSM criteria) are better served by specialty treatment. The DSM-5 classifies the severity of the diagnosis, Substance Use Disorder, based on the number of criteria met: 2-3 is mild, 4-5 is moderate and 6-7 is severe (APA, 2013). The following factors should be considered when selecting the appropriate level of treatment for alcohol use disorders:

  • The severity of the substance use disorder based on DSM-5's classifications.
  • The presence of psychiatric comorbidities or other medical problems or conditions
  • The patient's treatment preferences and readiness to change
  • The patient's level of social support
  • The patient's insurance or resources
  • The availability of treatment or support resources in the area
  • Provider's training and experience in treating alcohol use problems
  • Success level at past treatment attempts
View ReferencesHide References

Brief interventions have different goals based on the target population: eventual abstinence for dependent drinkers and reduction of drinking for anyone considered to be at risk (Fleming 2004/2005). When undertaking this intervention, there are a number of treatment options which can be pursued.

Treatment Goal
Motivational Interviewing The primary goal of MI is to enhance patient motivation by discussing and resolving their ambivalence towards change. This can be done by helping the patient develop a discrepancy between what they believe about where he/she is now and where he/she wants to be in the future. Ideally, recognizing this would encourage a desire to change and a motivation to adhere to treatment (Miller & Rollnick 2002).
Pharmacotherapy Pharmacotherapy can be used in conjunction with other psychosocial treatments to improve both compliance with the medication regimen and treatment outcomes. The three main areas in which it is used are: during medically assisted withdrawal (detox), to treat co-morbid psychiatric conditions, and to promote abstinence during recovery.
Referral The goal of referral is to get specialized treatment for those patients who score between 20 and 40 on the AUDIT, which denotes the highest risk level. When a patient's risk is this high, a discussion of referral is warranted (Babor et al. 2001).
View ReferencesHide References
Babor T, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test: guidelines for use in primary care. World Health Organization: Department of Mental Health and Substance Dependence. Second Edition. 2001. Available at: Accessed on: 2008-10-10.
Fleming M. Screening and brief intervention in primary care settings. Alcohol Research and Health. 2004/2005; 28(2): 57-62. Available at: Accessed on: 2010-08-18.
Readiness to Change

While a patient may have been diagnosed with an alcohol use disorder, it is important to determine their readiness to change and accept treatment for this disorder. According to the trans-theoretical model of change, there are five stages a patient may go through, although many patients may fall between these categories (Prochaska and DiClemente 1982). Depending on the stage a person is in, he or she will respond differently to different types of information and motivation. The model below illustrates how an individual's perceptions and interest in changing a behavior may alter over time, and it provides a framework for determining an appropriate intervention.

Samet et al. (1996) suggest using one of the following questions to begin assessing the patient's readiness to change:

  • "Do you think that your alcohol use is a problem?"


  • "How much of a problem is your alcohol use?"

To read a description of each stage of change, mouse over each section.

Patients who are not at the preparation stage of change are likely to either turn down referrals or quickly drop out of treatment. Those who have reached (or passed) the preparation stage are receptive to referral and are much more likely to successfully complete treatment (Prochaska 2003). And in some models, relapse is a part of the cycle (following maintenance) and can signal a return to the pre-contemplation or contemplation stage (Moore et al. 2003).

View ReferencesHide References
Moore EE, Feliciano DV, Mattox KL. Trauma. McGraw-Hill Professional. 2003.
Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research and Practice. 1982; 19: 276-288. Available at: Accessed on: 2013-10-25.
Prochaska JO. Enhancing motivation to change. In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, eds. Principles of Addiction Medicine, 3rd ed. Chevy Chase, Md: American Society of Addiction Medicine. 2003.
Samet JH, Rollnick S, Barnes H. Beyond CAGE: a brief clinical approach after detection of substance abuse. Archives of Internal Medicine. 1996; 156(11): 2287-2293.
Basic Clinical Skills

Through the information and cases presented in this module, you will become more proficient in:

  • Assessing a patient's willingness to change his/her behavior
  • Motivating patients towards treatment
  • Performing a brief intervention for a patient who misuses alcohol
  • Referring patients who need more specialized care
  • Managing patients during treatment and potential relapse

This module also addresses these main core competencies that all health care providers should practice:

  1. Interpersonal skills
  2. Communication
  3. Professionalism
  4. Patient Care
How Can I Apply These Clinical Skills to My Patients?

All health professionals should motivate patients towards treatment. Even a short 5 minute conversation about negative health behaviors, such as alcohol misuse, can have a profoundly positive effect on patient health.


 For any diagnosis, assessing a patient's motivation or willingness to change their lifestyle or behaviors is the first step towards treatment. Brief interventions should be used to further motivate patients towards more positive health outcomes. 


 Nurses can also motivate patients towards treatment and may be the ones to search for referrals or continue the brief intervention dialog with patients.

Other Allied Health Professionals

For any patient, a brief intervention can go a long way towards improving patient health.

What Impact Can I Have On These Patients?


Patient #1: Melissa  -  Melissa comes in for her yearly physical.

Melissa's screening during her physical reveals unhealthy drinking habits. How can a brief intervention help Melissa?


Patient #2: Sam - Sam was recently admitted to the hospital for abdominal pain and is here on follow-up.

What can you say to Sam to motivate him to decrease his alcohol consumption?

  • All adults and adolescents should be screened yearly for alcohol misuse.
  • The CAGE and the AUDIT are the two most commonly used screening tests.
  • Different characteristics of screening tests and differences among the populations being screened affect the usefulness of the test.
  • Adapting existing clinic systems is one approach to implementing screening.
  • Many barriers to screening for alcohol use disorders exist.
  • Alcohol dependence and alcohol abuse are two different diagnoses.
  • Laboratory tests are used to corroborate the results of screens and interviews and for motivating/monitoring patients already in treatment.
  • Alcohol Abuse and Dependence share symptoms with several other diagnoses.
Dialogue with Walt


Doctor: Based on your responses, I'm concerned about the amount that you are drinking.
Walt: So? I'm enjoying my retirement. I've earned it.
Doctor: The amount that you are drinking is contributing to your high blood pressure.
Walt: I thought drinking wine was good for you.
Doctor: There is some evidence that a glass of wine may help blood pressure, but consuming more than the daily recommended amount actually damages the body.
Walt: So a little is good and a lot is bad.
Doctor: Correct. In addition, some of this may be age-related as there's the difference in how our body metabolizes alcohol as we age.
The physiology of older adults can change the way that alcohol is metabolized. Blood alcohol content increases (due to lower body water content and higher body fat) and cognitive function decreases as a result of alcohol consumption (Mehta et al 2006).
Walt: So the kids were right?
Doctor: They may have had cause for concern and I would like to see you decrease your drinking so that we can get this high blood pressure under control.
Practice Tips

When Walt came back for his follow-up, his blood pressure readings had decreased slightly after limiting his alcohol use.

Contributing health factors throughout the aging process can cause differences in how alcohol is metabolized and actually cause alcohol to affect the body more strongly than in earlier years. Although there are reported health benefits to moderate alcohol consumption, these benefits should be compared to the negative impacts of alcohol on the health and well-being of older adults (Merrick et al 2008). Awareness of this increased health impact should be counseled on and intervention measures taken accordingly.

Walt came in with high blood pressure, which is a common symptom among older adults. However, it is important not to immediately attribute a common symptom with the most common diagnosis. By getting a more thorough case history, you can more accurately diagnose the underlying issue.


Doctor: This is your third visit with us in two weeks and unfortunately the results of your blood pressure test still remain high.
Walt: Probably just a normal sign of aging, huh?
Doctor: Not necessarily. I'd like to try to pin down exactly what might be causing this so that we can get it lowered. High blood pressure, over time, can cause all kinds of negative health reactions.
Walt: Like what? I know if it gets too high you can have a heart attack, but my results weren't extreme like that.
Doctor: It can damage not only your heart, but also your kidneys, brain, eyes, and possibly lead to stroke.
Walt: I definitely want to get to the bottom of this then!
Doctor: We went through the regular health questionnaire when you came in for your physical. You indicated that you're still drinking?
Walt: Yeah, the wife and I joined a winery tour this year, so we're traveling around to vineyards.
Doctor: How many drinks do you consume now?
Walt: Well, we do the winery tour twice a month and then we have our regular wine with meals, so it probably comes out to about five times a week?
Doctor: Ever drink more than six drinks at once?
Walt: Twice a year when we do the collective winery tour.
Doctor: Do you think your drinking is impairing your life? Can't stop drinking? Not being able to do your normal daily routines?
Walt: Nope, I'm fine.
Doctor: Have you ever been unable to remember what happened after you drank?
Walt: Maybe once or twice, but that's just old age.
Doctor: Has anyone suggested you cut down on your drinking?
Walt: The kids got a little concerned this year since we're doing the tour, but they worry too much anyway.
It's been shown that alcohol directly contributes to raising blood pressure and by reducing that intake blood pressure can drop in as little as 1-4 weeks (Stewart et al. 2008).

View ReferencesHide References
Stewart SH, Latham PK, Miller PM, Randall P, Anton RF. Blood pressure reduction during treatment for alcohol dependence: results from the Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study. Addiction. 2008; 103: 1622-1628.
Meet Walt

WaltWalt is a 64-year-old former factory worker. He was a dedicated worker and had the respect of all his peers. Walt retired early last year and since that time he and his wife have enjoyed spending time with their grandchildren and traveling around the country when they have a chance.

Reason for Visit

Walt comes to your office for his annual physical. Most of his results are unremarkable for his age. His weight is in the normal range, no disorders on his blood tests, and has no respiratory stress. However, when taking his blood pressure the test indicates that it is high (160/100).


Assessment for intervention should be done once the severity of a patient's alcohol use problem has been determined.

For patients who are at-risk drinkers, but who do not meet the criteria for a substance use disorder, a brief intervention is appropriate. They are informational and motivational in nature, designed specifically to be delivered to patients in the primary care setting.

For patients with more severe alcohol use problems (i.e., alcohol abuse or dependence), patients with significant medical or psychiatric comorbidities, and at-risk patients for whom brief interventions have proven ineffective, the best option is typically referral to a substance abuse professional or program. This will give these patients access to procedures and therapies that are not usually feasible in primary care, including medically-assisted withdrawal (detoxification), psychosocial therapy, and self-help groups.


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