Within the literature, the terms “brief” and “minimal” interventions cover a range from one five minute interaction to several 45 minute sessions. The major positive studies discussed in this section typically consist of one interaction lasting between five and 20 minutes, sometimes with one brief follow up contact.

The acronym FRAMES⁴⁵ captures the essence of the interventions commonly tested under the terms “brief intervention” and “motivational interviewing”:

• Feedback: about personal risk or impairment
• Responsibility: emphasis on personal responsibility for change
• Advice: to cut down or abstain if indicated because of severe dependence or harm
• Menu: of alternative options for changing drinking pattern and, jointly with the patient, setting a target; intermediate goals of reduction can be a start
• Empathic interviewing: listening reflectively without cajoling or confronting; exploring with patients the reasons for change as they see their situation
• Self efficacy: an interviewing style which enhances peoples’ belief in their ability to change.

This guideline uses “brief intervention” throughout to cover short duration interventions which use the FRAMES style. The efficacy studies on brief interventions quoted have almost always excluded alcohol dependent patients because they were deemed inappropriate for this intervention.

3.1 Brief interventions in general practice

There is consistent evidence from a large number of studies that brief intervention in primary care can reduce total alcohol consumption and episodes of binge drinking in hazardous drinkers, for periods lasting up to a year. There is limited evidence that this effect may be sustained for longer periods. All groups under study reduced alcohol consumption, but those with brief interventions did so to a greater extent than those in control groups. Very brief interventions (5-10 minutes) may have a similar effect to extended interventions (20-45 minutes or several visits), although the evidence is not consistent.^{46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57} Evidence level 1++,1+

Studies have varied in whether the intervention is given on the day of detection or later, without revealing a preferred timing. Some successful studies have used a booster contact (a follow up intervention at a later date).^{58, 59} Evidence level 1++,1+

There is some evidence that the use of written media such as booklets or leaflets enhances the efficacy of brief interventions.⁶⁰ Evidence level 1++,1+

The optimum type of intervention is still to be defined. Sometimes “advice” is given, while at other times the style of interaction epitomised in “motivational interviewing” has been used. Additionally, the comparative value of opportunistic intervention, versus intervention after population screening is not clear.

Data on follow up beyond one year are very limited.⁶¹ One study found that the effect had disappeared at 10 years.⁶² Another found a continuing small effect at four years.⁶³ A 10-16 year follow up of a sample recruited in a screening project found that intervening had reduced mortality, but the original intervention comprised sessions repeated regularly over up to two years – much more than a brief intervention.⁶⁴ Evidence level 1+,3,4

The evidence does not support the use of brief interventions for more severely affected patients seeking treatment.⁵⁷ A brief intervention is effective at the point when the hazardous or harmful drinker is newly identified (ie an opportunistic encounter).⁵⁴ This may be during attendance for a related or even unrelated illness or injury, at health screening for employment or insurance purposes, or at the time of registering with the practice (see Box 1).

The effectiveness of brief interventions has been reported as number needed to treat (NNT) of 7-9. That is between seven and nine patients will need to be given a brief intervention in order to achieve a reduction of drinking to within non hazardous levels in one patient.^{54, 56, 63} Evidence level 1++,1+

This compares favourably with treatment for other medical conditions (eg the use of statins to prevent cardiovascular mortality following myocardial infarction over trial duration, NNT=30-90⁶⁵ or the use of antihypertensive therapy to prevent a cardiovascular event within five years, NNT=40-125).⁶⁶

In research studies of brief intervention, patients were recruited by screening all attenders at the practice, or all those on the practice list. Of attenders screened, less than 5% met criteria and entered the treatment arm.^{54, 58, 67, 68, 69, 70} Thus, at an NNT of eight, 1000 patients would need to be screened for around six patients to show clear benefit. For this reason, primary care professionals should rely on case detection based on clinical presentation, with judicious use of questionnaire tools where there is suspicion, rather than the screening of whole populations.

General Practitioners and other primary care health professionals should opportunistically identify hazardous and harmful drinkers and deliver a brief (10 minute) intervention. The intervention should, whenever possible, relate to the patient’s presenting problem and should help the patient weigh up any benefits as perceived by the patient, versus the disadvantages of the current drinking pattern.

Box 1: Screening and brief interventions

Assisting goal of reduction	Assisting goal of abstinence	* Absolute indications for abstinence: alcohol related organ damage severe dependence (eg morning drinking to stop the shakes or previous failed attempts to control drinking) significant psychiatric disorders Relative indications for abstinence: epilepsy social factors (eg legal, employment, family)
Elicit patient’s concerns Regular review to offer encouragement Monitor (see or telephone patient, information from family/GGT) Reassess with patient the costs and benefits of change	Enlist support of family and friends Consider use of local alcohol services Plan medically assisted withdrawal if indicated, at home or in hospital Recommend Alcoholics Anonymous, especially if other support for abstinence is lacking Consider specific pharmacotherapy: acamprosate (reduces intensity of and response to cues and triggers to drinking) and/or disulfiram (deterrent) Initiate active intervention if other psychiatric problems (depression/anxiety) persist >2 weeks Monitor (see or telephone patient; information from family/GGT)

Based on the UK Alcohol Forum guidelines for the management of alcohol problems in primary care and general psychiatry.³⁵

3.1.1 TRAINING

Training healthcare providers in the use of structured interventions enhances the efficacy of brief interventions.⁷¹
Training practice nurses at health centres in screening and delivering brief interventions has the potential for increasing the availability of these services, but more research is needed to verify this.⁷¹

There are well documented difficulties in disseminating research findings to primary care providers. Research on implementing screening and brief alcohol intervention showed personal meetings to effect most behaviour change in GPs, but ongoing telephone support to be the most cost effective measure.^{72, 73, 74}

Training is required in order to deliver effective brief interventions.

Training for GPs, practice nurses, community nurses and health visitors in the identification of hazardous drinkers and delivery of a brief intervention should be available.

3.2 Brief interventions in the accident and emergency setting

A few studies have been conducted of brief interventions to non-admitted A&E patients. One involved the use of a routine follow up letter to patients advising attendance at alcohol counselling services. The letter appeared to be useful in encouraging a significant minority of people to attend appropriate specialist services.⁷⁵ The use of follow up correspondence may be a low cost intervention which could produce positive results but more research is needed in this area. Evidence level 1+

Another study delivered an onsite intervention to adolescents presenting with alcohol problems and showed a positive effect of a single intervention in this patient group.⁷⁶ This study has limitations in its design and only applies to a limited subset of A&E attenders. Evidence level 1-

A third study compared standard care, motivational interviewing or motivational interviewing plus a booster session 7-10 days later.⁵⁹ This study recruited injured patients who screened positive for harmful or hazardous drinking. At one year follow up, the “motivational interviewing plus booster session” group reduced their alcohol related injuries by 30% more than those who received standard care. There was no difference between standard care and a motivational interview offered at the time without the booster session. The interventions were delivered by research staff trained in motivational interviewing. Evidence level 1+

In A&E departments where brief interventions are offered by busy A&E staff, uptake of such interventions by patients may be very low.⁷⁷

When conducted by specially trained and allocated staff offering and arranging follow up, brief intervention can be beneficial. There is insufficient evidence however, to recommend routine brief intervention alone in A&E.

Patients who screen positive for harmful drinking or alcohol dependence in A&E should be encouraged to seek advice from their GP or given information on how to contact another relevant agency.

3.3 Brief interventions in the antenatal setting

Advice from the Health Education Board for Scotland (now NHS Health Scotland) is that light, occasional drinking during pregnancy (one or two units once or twice a week) is not likely to do any harm.⁷⁸ Heavy drinking is associated with miscarriage, and sometimes with serious effects on the baby’s development.⁷⁸ Some authorities recommend complete abstinence during pregnancy (the US National Institute on Alcohol Abuse and Alcoholism:http://www.niaaa.nih.gov/publications/brochure.htm).

Two studies have been identified which looked at brief interventions in the antenatal setting. One study, in women of childbearing age identified by screening as “at-risk drinkers”, compared giving the patient a booklet without additional advice with two 15 minute physician consultations that incorporated a workbook, a drinking agreement and drink diary cards. Both groups reduced consumption with the physician intervention group reducing consumption to a greater extent. Differences overall were significant but the magnitude of difference between groups was small. Subjects who became pregnant however, showed the greatest reduction.⁵³ Evidence level 1+

A study of women receiving antenatal care compared an “alcohol consumption assessment only” group with a brief intervention group. Both groups reduced their drinking during the rest of the pregnancy, but differences in reductions by group were not statistically significant. Those who received the brief intervention maintained higher rates of abstinence.⁷⁹ Evidence level 1+

Routine antenatal care provides a useful opportunity to deliver a brief intervention for reducing alcohol consumption.

3.4 Effectiveness of motivational interviewing

Motivational interviewing (a non-judgemental interviewing style which avoids confrontation, helps the individual weigh up the pros and cons of change, and enhances self efficacy) is a style which is helpful in brief interventions (see Annex 5).⁸⁰ A systematic review showed that motivational interviewing has a significant effect on reducing alcohol consumption in the primary care setting.⁸¹ There is no evidence to support a confrontational style of interviewing. Evidence level 1+

Motivational interviewing techniques should be considered when delivering brief interventions for harmful drinking in primary care.

Staff who deliver motivational interviewing should be appropriately trained.