Brief Screening
for High-Risk Drinking
Motivating anyone to rethink an established behavior let along a personal opinion on a controversial topic is a daunting task to say the least. As a matter of fact, when one's drinking (or other drug use) is the object of a motivational intervention, this is often an even greater task. This is nowhere more the case then when a medical professional seeks to engage a patient in a conversation about his or her alcohol (or other drug) use.
For many, both medical professional and patient alike, there seems to be a vicious circle when it comes to considering motivating change where alcohol consumption is involved. This cycle, some might call it the futility cycle, is represented in this graphic courtesy of Dispair, Inc:
Ultimately, the medical professional will simply "stop asking" about use beyond the ubiquitous "do you drink" and if learning, "yes, a couple," leave it at that. Unfortunately, with substance use disorders representing one of the major medical challenges in the 21st century, at least in Western countries, this effectively nullifies early intervention by someone who may, interestingly, have the greatest likelihood of being listened to by a substance using individual...his or her medical professional.
To
quickly screen for alcohol-related problems, consider using the four questions
that follow (see http://bit.ly/NTuITs for source
material). The first has been suggested as a “single question” capable of
determining if further screening, if not a formal assessment, is warranted and
is argued in the cited article to be, in and of itself, sufficient to discern
if a problem exists or not.
- Monthly or more often suggests a positive screen, indicating that the respondent might benefit from an intervention to help him or her cut back.
- How often in the last 6-months have you been unable to recall some or all of what happened during the previous night’s drinking?
- How often in the past 6-months have you be unable to follow through with normal responsibilities following drinking?
- How often in the last 6-months have you experienced concern about your drinking expressed by a family member, relative, or friend?
If
the answer to the first question is no, and the interviewer believes the
response is genuine, consider your screening complete. If, however, you
question the veracity of the response to question #1 or that answer is
positive, then questions 2 – 4 make sense to ask.
NOTE
#1: You may want to consider “working these in” over the History & Physical
rather than risk appearing to conduct an interrogation.
Note
#2: Most individuals, especially those who have a substance use disorder (SUD),
know how to answer such questions so as to appear “lower, if not a low
risk.” It is therefore recommended to familiarize yourself with
these questions so you can “work them into” a conversation with someone being
screened. A secondary approach to conducing this screening, if time
permits, is to invite the interviewee to “tell his story” and then answer each
question for the interviewee in your mind based on the facts in the reported
story.
If
the individual does not volunteer needed information necessary to answer each
question, use open ended questions to access such. For example, if the
individual’s story does not allow you to answer the question, “How often in the
last 6-months have you been unable to recall what happened during the previous
night’s drinking?”, try asking, Tell me something about how drinking affects
your memory. If the individual is hesitant or allusive, try something
a bit more direct, for example, when drinking, rate your ability to
consistently and accurately recall events the next day.
Remember
that effective screening necessitates never attacking or simply interrogating
an individual. If the person does not have a problem, such techniques
will only serve to alienate the individual while if a problem does exist, it
will only alert the individual to your perceived intent…to label and likely
show condescension based on that label.
If
the results of this brief screening suggest the likely problem with alcohol,
ask the individual’s permission to share proactive suggestions about how he or
she can pursue the issue further. If the permission is not
forthcoming, then share your concerns for the individual’s health and
wellbeing based on the suggested results of the brief screening.
A
simple set of follow-up questions include:
1.
What
are the good things—and phrase it this way—about drinking? Note: This is
a “throw away question” because everyone will answer it according to personal
preferences. The benefit of this question is that it established your
interest in the person and his or her opinion.
2.
The
second question is, What are the less good things—and again, state it
exactly this way—about drinking.
You
will notice that the answer to the second question, which is the important
question, will often (always?) mimic the problems that patient associates with drinking. If, however, the
interviewer were to ask, “Tell me about your problem with alcohol” or “What
problems do you experience when you drink,” you will likely get something like,
“Well, I don’t really have any problems when I drink” or “I don’t have a
drinking problem.”
The
purpose of this brief intervention is not to get people with
alcohol problems to admit that their drinking is a problem. The purpose
is to increase the likelihood that individuals will step outside their comfort
zone and look at their drinking from a different perspective. Just as the
answer to the question, “is 2 minutes a long time or a short time” is dependent
on the individual’s perspective regarding time. If, for example, the
individual said this is a short amount of time, ask him or her to hold
his or her breath for 2-minutes and watch for the reaction.
