Getting into the holiday SBIRT: how do you help patients cut back on drinking?

You met Ivy two years ago. Your clinic had just implemented universal screening for unhealthy alcohol use as per the 2018 USPSTF recommendation using the National Institutes on Alcohol Abuse and Alcoholism (NIAAA) single item screening question “How many times in the past year have you had *** (4 for women, or 5 for men) or more drinks in a day?”(O’Connor 2018). Ivy screened positive. 

You asked permission to discuss alcohol with her and learned that once a week she’ll have 4 drinks in one sitting with friends. Using patient-centered questions (see prior PsychSnaps on taking a substance use history and diagnosing a substance use disorder), you clarified that Ivy does not have chaotic alcohol use or an alcohol use disorder (AUD). You shared the healthy limits for alcohol intake for women (no more than 3 at one time or 7 in a week) and told Ivy that she met criteria for drinking above the dietary guideline recommendations. After hearing this, Ivy decided that she was going to cut back on her drinking.

It is now 2 years later, and Ivy tells you she’s here to discuss drinking. She has 4 cocktails on Saturdays and 1-2 glasses of wine a night with her partner. You show her NIAAA’s cocktail calculator and learn that her 4 mixed drinks are actually 6 standard drinks on Saturdays. Ivy says this pattern of drinking started during COVID. Ivy does not report any problems from the alcohol aside from being a bit tired on Sunday mornings.

You ask Ivy if you can share some information about the health effects of this level of drinking. In the discussion, you share that the greater the weekly volume of alcohol and the more frequent the heavy drinking days, the greater the risk of developing AUD according to NIAAA. Drinking beyond healthy limits also increases Ivy’s chance of developing hypertension, heart disease, anxiety, depression, liver disease, and cancer (head & neck, GI, and breast), and of being injured due to reduced reaction time. Ivy is also thinking about starting a family, so you make a mental note to talk with her about the risks of alcohol for a fetus and mother in the future. Ivy appreciates the health risks you share.

Throughout the conversation, you’re using the skills of SBIRT (Screening, Brief Intervention, and Referral to Treatment. You emphasize the behavioral intervention (BI) because her screening was positive, and she doesn’t have an alcohol use disorder to warrant referral to treatment outside of your office. Sharing with Ivy that her drinking is above recommended levels and that there are potential health implications is a BI. The most robust evidence for the “BI” in SBIRT is for people like Ivy who screen positive for unhealthy alcohol use in primary care. BI (alone) would not be an effective treatment for alcohol use disorder.

The counseling you provide as part of these BI steps is quite powerful: a JAMA 2018 article found that counseling interventions and sharing healthy limits resulted in an “absolute increase of 14 percentage points in the likelihood of a patient drinking within recommended limits.” Put another way, 7 adults would need to be treated [with BI] for 1 person to drink within recommended limits–that’s pretty great from a NNT standpoint (O’Connor 2018). 

The American Public Health Association spells out these effective steps for BI:

Establish Rapport
Raise the subject (of alcohol use)
Provide feedback1. Review drinking patterns
2. Make connection between alcohol use and any health problems or reason for visit
3. Compare use to healthy drinking guidelines
Enhance motivation1. Assess readiness to change
2. Help patient see difference between their behavior and concerns
Negotiate and advise1. Negotiate a goal
2. Build self-efficacy
3. Give advice
4. Summarize
5. Follow up

Ivy presented to the appointment wanting to make a change in her drinking. After inviting her to share her reasons for wanting this change, you briefly summarize them and move on to “Negotiate and advise.” In negotiating a goal around drinking, you ask her what realistically she could do and wants to do to reduce the drinking. Ivy thinks that her Saturdays out with friends are hitting her wallet too hard, and to save money, she plans to cut back to 2 drinks or less while out at restaurants or bars. You then review her confidence in being able to meet this goal, and Ivy states that she is “pretty sure” she can cut back to 2 drinks a night on Saturdays.

To support Ivy’s self-efficacy, you offer that some patients have found it helpful to use an app-based program to reduce their drinking. A recent study out of Switzerland showed that providing access to a (home-grown) smartphone app for a year was effective at reducing the average drinking amount for young adults with unhealthy alcohol use at higher education programs (including students of Ivy’s age in graduate programs; Bertholet 2023). However, a systematic review in 2020 found that although most app interventions for reducing alcohol, tobacco, and drug use were associated with reductions in problematic substance use, less than a third were significantly better than comparison conditions after the treatment period (Staiger 2020). 

The 3 apps listed below aim at reducing alcohol use and are available in the United States. They do not have evidence from randomized controlled trials to support their efficacy. 

Reframe shares lessons on alcohol and health connections; includes progress tracking, motivational skill-building, & virtual support groups. $25/month, $120/year.
Drinker’s Helper tracks drinking (free); builds skills and offers support group. $40/3 months, $60/6 months.
Nomo tracks drinking, free.

Ivy chooses to download Reframe while in the office with you because she liked the option of having a personalized plan to manage her drinking goals.

Finally, you borrow from recovery counseling to provide advice. You suggest that Ivy spend time reflecting on the people, places, and things that may push her to drink above her goal and think ahead of time how she might manage them. She might consider saying to family members who offer her drinks, “Thanks for the offer. I’m not drinking right now” or “My goal is one cocktail tonight and this glass is it.” She tells you there is one cousin who she is close with who can be an accountability partner for her at family gatherings over the holidays. Before Ivy leaves, you plan another visit for mid-January to follow-up on her goals (an important last step in SBIRT).


Key Points

  1. Unhealthy alcohol use is associated with increasing risk of bodily harm, AUD, and developing or worsening many medical and psychiatric conditions. 
  2. The counseling around unhealthy alcohol use (the BI in SBIRT) has a NNT of 7 for drinking within healthy limits.
  3. Mobile apps may be an accessible support to help patients reduce drinking.

Related PsychSnaps:

“How do you talk to patients about their substance use?” September 25, 2023

“How do you diagnose and treat substance use disorder?” June 30, 2023


References:

Bertholet N, Schmutz E, Studer J, Adam A, Gmel G, Cunningham JA, McNeely J, Daeppen JB. Effect of a smartphone intervention as a secondary prevention for use among university students with unhealthy alcohol use: randomised controlled trial. BMJ. 2023 Aug 16;382:e073713.

O’Connor EA, Perdue LA, Senger CA, et al. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018;320(18):1910–1928. 

Staiger PK, O’Donnell R, Liknaitzky P, Bush R, Milward J. Mobile Apps to Reduce Tobacco, Alcohol, and Illicit Drug Use: Systematic Review of the First Decade. J Med Internet Res. 2020 Nov 24;22(11):e17156. 


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