By Amy O’Donnell, Newcastle University, UK

Levels of drinking have fallen recently in some parts of Europe, particularly amongst young people. However, excessive alcohol consumption remains a major risk factor for poor health and early death. Providing simple brief advice to those identified as heavy drinkers can help reduce the amount of alcohol people consume, especially when delivered by primary care clinicians such as general practitioners (GPs) or nurses. Alcohol brief advice involves a short, evidence-based, structured conversation that aims to motivate and support a patient to consider a change in their drinking behaviour to reduce their risk of harm. We still haven’t fully identified the key ingredients of these conversations, but providing personalised feedback on a patient’s alcohol consumption, and encouraging them to self-monitor their drinking, seem to be particularly effective parts of the package.

However, getting evidence-based treatments and interventions into routine healthcare is a slow and tricky business. Some estimates suggest it takes 17 years on average for research findings to make their way into everyday clinical practice. After three decades of research, 70+ randomised controlled trials, and numerous reviews of published studies, brief alcohol advice is still not routinely delivered in global primary healthcare systems. To understand why brief alcohol advice has not been fully integrated to primary care, we need to consider many different perspectives on the problem, including the views of those who provide healthcare (clinicians), and those who use it (patients).

So, what do the people involved in delivering and receiving alcohol brief advice in primary care tell us about the challenges they face?

Some common issues raised by GPs and nurses include not having enough time, training, or financial resources to deliver alcohol advice to their patients. However, providing extra payments to GPs for alcohol work is not necessarily an effective implementation strategy. One recent study found that introducing financial incentives for alcohol advice in English primary care had almost no impact on delivery rates. Other research suggests that clinicians’ attitudes and beliefs about the relevance, sensitivity, and overall value of discussing alcohol in routine patient consultations could play a bigger part in influencing their practice. For example, some GPs doubt that their patients will be receptive to advice about changing their drinking behaviour, particularly very heavy drinkers. This is partly due to a lack of confidence in the effectiveness of psychological therapies for excessive alcohol consumption, but also because GPs are concerned that they might offend patients by raising the topic of drinking in the first place.

Less research has explored patients’ perspectives on these issues. Studies report that most people think it is acceptable for GPs or nurses to ask about their alcohol consumption, and view such lifestyle advice as a valuable part of healthcare, particularly for those with underlying and/or alcohol-related health conditions. Like some doctors, however, patients are less sure that heavy drinkers would be open to talking about their alcohol consumption with clinicians, at least not truthfully. Yet the bigger challenge is that many patients show limited awareness about their own level of drinking. This is partly because calculating how much alcohol is actually in that glass of wine or gin and tonic is pretty difficult, and it can be easy to lose track when you are pouring drinks without standardised measures at home.

But it is also because for many of us, alcohol consumption isn’t viewed in terms of how much it increases our risk of particular conditions and diseases (i.e., the way that clinicians, public health practitioners or epidemiologists see drinking), but rather in terms of the central role it plays in fun, pleasure and celebration. This means that some patients might be reluctant to recognise either that they are drinking too much, and/or question why their healthcare provider is asking them to cut down. Linked to this issue, patients tell us they already carry out a range of strategies to limit their drinking, but see these as based on ‘life lessons’ learned from their own families, friends, and social groups. So again, some patients see limited benefit in the advice that GPs or nurses might offer about drinking, which can seem disconnected from real life.

Practical recommendations

So how can we use all these views, perceptions, and experiences to improve the implementation of alcohol brief advice in primary healthcare?

• First, rest assured that it is OK to ask about drinking. There is little evidence patients will take offence if you ask about their drinking habits.
• Be sure to ask questions about ‘how’ and ‘why’ patients actually drink, rather than simply ‘how much’. This will boost the relevance and meaning of any advice you give, by acknowledging the social and cultural values that shape patients’ drinking.
• Next, based on what patients tell you about the situations in which they are most likely to drink heavily, help them to develop preventive strategies specifically targeted to those critical moments of risk. Where possible, build these strategies around the types of tactics that many patients already see as feasible and effective. For example, by limiting drinking in particular settings, such as at home, or with particular social groups, such as children.
• Finally, given that clinical time is always limited, focus on delivering brief alcohol advice to patients who present with conditions where there is a recognised link with heavy drinking, such as high blood pressure, mental ill-health, or gastric problems. This will help to target the use of precious resources, and may also be more acceptable and engaging for patients themselves.

Funding acknowledgement

This research was funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views are those of the author(s) and not necessarily those of the NIHR, the NHS or the Department of Health.