Patients with alcohol problems in primary care - Understanding their resistance and motivating change

Alcohol risk and harm reduction is a both a clinical and public health appr oach that goes beyond specialized treatments for alcoholism.(14.17) This se condary prevention approach has been described in an Institute of Medicine Report(19) as one that will broaden the base for reducing alcohol problems in the population. The greatest potential for reducing alcohol risk and har m in a population depends on the extent to which practitioners use secondar y prevention programs in primary care and in hospital settings. In the Unit ed States general population, the implementation of safe drinking limits wo uld result in an estimated 14.2% and 47.1% reduction in the prevalence of a lcohol abuse and dependence, respectively.(2) The implementation issues, ho wever, are significant.(5,48) In primary care and hospital settings, practitioners can identify patients who drink alcohol at hazardous and harmful levels and use brief interventio ns to help them reduce both their excessive alcohol intake and the associat ed risks and harmful effects.(45,50) With this goal in mind, the College of Family Physicians of Canada (CFPC) and the National Institute of Alcoholis m and Alcohol Abuse (NIAAA) published materials specifically for use by pri mary care physicians.(12,30) Both approaches use the traditional advice-giv ing approach based on the National Institute of Cancer (NCI) model of smoki ng cessation (the four A's model: ask, assess, assist, and arrange follow-u p). These action-oriented approaches are helpful fur the minority of patien ts who are ready for change. The advice-giving approach is helpful for patients fur are ready for change . Up to 20% of patients with excessive alcohol intake reduce their consumpt ion to below low-risk limits in response to physician advice.(3,15,16,21,33 ,46,47) Such advice-giving is less likely to work with patients who are not thinking about change or are ambivalent about it. Practitioners also need to learn how to motivate resistant patients to chan ge. As part of this process, they can help patients decide whether to chang e their perceptions and values in ways that lower their resistance and enha nce their motivation. An understanding of resistance is central to practiti oners' effectively learning how to use motivational interventions with pati ents. Not all brief interventions, however, are the same or equally effecti ve.(17) The challenge for practitioners is how to generate a dialogue with patients in ways that help develop individualized interventions. This artic le is divided into two sections: understanding patient resistance; and usin g a six-step approach for motivating change. Both sections can help practit ioners develop individualized interventions to meet patients' needs.