Introduction

When hazardous or harmful drinking is first identified in primary care or the hospital setting, patients should be offered brief intervention. This consists of 10 minutes of discussion and explanation, provision of a self-help booklet, and the offer of a further appointment in one or two weeks. Its cost effectiveness has been proved, although time may have to be set aside rather than trying to undertake intervention within normal practice. Training and employing a member of staff for the purpose is worth consideration.

Motivational interviewing

The value of motivational interviewing is proved. This essentially is an empathic, non-confrontational approach in which the doctor helps the patient identify his or her own reasons for change and strategies for achieving realistic goals. Essential components include sustaining commitment over time, involving the family when possible, acknowledging achievements, and dealing promptly with lapses. A patient's motivation to change his or her way of life fluctuates according to mood and circumstance, and patient and doctor can feel deflated by early setbacks.

The primary care team is ideally suited to provide long term support. Barriers to change need to be identified: some patients will have few barriers; others will have serious impediments that need to be dealt with.

Dependence and detoxification

Some patients will find it hard to cut down or stop drinking because they experience withdrawal symptoms. At first, these may not be recognised for what they are. Patients may describe feeling nervous without a drink or not being able to function effectively until the first drink of the day. Other features in patients who are physically dependent will provide supportive evidence. They vary in severity.

Mild symptoms can be dealt with by rest, relaxation, and reassurance. An explanation that withdrawal symptoms are evidence that the brain has adapted to living in an alcoholic environment …