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14 September 2012


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.

1.      How often do you have eight (or for women, six) or more standard drinks[1] on one occasion?[2]
      
  • 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.


[1] A standard drink = 1.5 oz 80 proof spirits, 12-oz domestic beer, 10-oz malt liquor, 5-oz table wine.
[2] Most descriptions of high-risk or what some call binge drinking suggest 5 or more standard drinks for males, 4 or more for females, but this is a controversial bench mark

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