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Four Steps at a Glance

Refer to the following pages for detailed steps.

Step 1: Ask the two age-specific screening questions

- One about friends' drinking

- One about patient's drinking frequency

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NO
<- Does the patient drink? ->YES

Step 2: Guide Patient

For patients who do not drink alcohol


Step 2: Assess Risk

For patients who do drink

  • Reinforce healthy choices

 If friends drink:

  • Explore your patient's view about this.
  • Ask about his or her plans to stay alcohol free. 
  • Rescreen at next visit.

If friends don't drink:

  • Praise the choice of nondrinking friends.
  • Elicit and affirm reasons for staying alcohol free.
  • Rescreen next years

  • Identify Lower, Moderate, or Highest Risk level using the age-specific risk chart on page 10
  • Use what you already know about your patient, and ask more questions as needed.

 

Screening complete for patients who do not drink
Step 3: Advise and Assist

Lower Risk

  • Provide brief advice to stop drinking

Moderate Risk

  • Provide brief advice or, if problems are present, conduct brief motivational interviewing.
  • Arrange for followup, ideally within a month.

Highest Risk

  • Conduct brief motivational interviewing.
  • Consider referral to treatment.
  • Arrange for followup within a month.

Step 4: At Followup, Continue Support

  • Ask about alcohol use and any related consequences or problems.
  • Review the patient's goal(s) related to alcohol and his or her plans to accomplish them.
  • Offer support and encouragement.
  • Complete a full psychosocial interview, if not done at the previous visit.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 1: Ask the Two Screening Questions

Research indicates that the two age-specific screening questions (about friends' and patient's drinking) are powerful predictors of current and future alcohol problems in youth. Fit them into your office practice in whatever way works best for you, whether by adding them to a pre-visit screening tool or weaving them into your clinical interview. In either case, take steps to protect patient privacy and, if at all possible, conduct an in-person alcohol screen when you are alone with your patient. See page 25 for more information about confidentiality. 

Guidelines for asking the screening questions: (1) For elementary and middle school patients, start with the friends question, a less threatening, side-door opener to the topic of drinking. (2) Because transitions to middle or high school increase risk, choose the question set that aligns with a patient's school level, as opposed to age, for patients aged 11 or 14. (3) Exclude alcohol use for religious purposes.

Elementary School
(Aged 9-11)

Ask the friends question first.

Friends: Any drinking?

"Do you have any friends who drank beer, wine, or any drink containing alcohol in the past year?"

ANY drinking by friends heightens concern.

Patient: Any drinking?

"How about you - have you ever had more than a few sips of beer, wine, or any drink containing alcohol?"

ANY drinking:
HIGHEST RISK

Middle School

(Aged 11-14)

Ask the friends question first.

Friends: Any drinking?

"Do you have any friends who drank beer, wine, or any drink containing alcohol in the past year?"

ANY drinking by friends heightens concern.

Patient: How many day?

"How about you - in the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol?"

ANY drinking:

Moderate or Highest Risk

(see chart on page 10)

High School

(Aged 14-18)

Ask the patient question first.

Patient: How many day?

"In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol?"

Lower, Moderate, or Highest Risk

(see chart on page 10)

Friends: How much?

"If your friends drink, how many drinks do they usually drink on an occasion?"

 

Binge drinking by friends heightens concern.

(3 to 5+ drinks; see page 15)

NO
<- Does the patient drink? ->YES
Go to Step 2: Guide
Go to Step 2: Assess Risk

Step 2: Guide Patient

For patients who DO NOT drink...

NO
<- Do friends drink? ->YES

Neither patient nor patient's friends drink

  • Praise choices of not drinking and of having nondrinking friends.

Patient does not drink, but friends do

  • Praise choice of not drinking.
  • Consider probing a little using a neutral tone: "When your friends were drinking, you didn't drink. Tell me a little more about that." If the patients admits to drinking, go to Step 2 for Patients Who Do Drink; otherwise, continue below.
  • Reinforce healthy choices with praise and encouragement: "You've made a smart decision not to use alcohol."
  • Elicit and affirm reasons to stay alcohol free: "So, what led you to the decision to stay away from alcohol?" If friends drink, add, "...especially when your friends have chosen to drink?" Possible followup: "Those are great reasons and show you really care about yourself and your future."
  • Educate: If your patient is open to input, you may want to help him or her understand, for example, that (1) alcohol can affect brain development, which continues into a person's twenties; and (2) drinking at an early age increases the risk for serious alcohol problems later in life.
  • Rescreen next year at the latest.
  • Explore how your patient plans to stay alcohol free when friends drink: Ask patients for their ideas on handling situations where they may feel pressure to drink. You can let them know that often the best response to a drink offer is a simple "No, thanks"; that, if pressured, an effective response is "I don't want to"; and that they don't have to give a reason.
  • Advise against riding in a car with a driver who has been drinking or using other drugs.
  • Rescreen at next visit.
Screening complete for nondrinkers

 

Step 2: Assess Risk

For patients who DO drink...

For a broad indicator of your patient's level of risk, start with the chart below, which provides empirically derived population-based estimates. Then factor in what you know about friends' drinking and other risk factors, ask more questions as needed, and apply your clinical judgment to gauge the level of risk.

image.png

In the chart, see where your patient's age and drinking frequency intersect: If your patient responds to the screening question with a per-month or per-week frequency, convert the answer to days per year to see where the drinking falls on the risk chart. As an example, a 15-year-old who reports drinking about twice a month, or 24 days in the past year, is at “highest risk” for adverse consequences. (This chart is also in the Pocket Guide; see page 19 for tips on remembering the risk level cut points.) 

Factor in friends:

  • For elementary and middle school students: Having friends who drink heightens concern. Because having more drinking friends means more risk, ask how many friends drink, if your patient didn’t offer this detail when answering the screening question. 
  • For high school students: Having friends who binge drink heightens concern. Recent research estimates that binge drinking levels for youth start at 3 to 5 drinks, depending on age and gender (see page 15).

Include what you already know about the patient’s physical and psychosocial development in your risk evaluation, along with other relevant factors such as the level of family support, drinking and smoking habits of parents and siblings, school functioning, or trouble with authority figures.

For moderate risk and Highest risk patients: 

  • Ask about their drinking pattern: : “How much do you usually have? What’s the most you’ve had at any one time?” If the patient reports bingeing (see page 15), ask: “How often do you drink that much?”
  • Ask about problems experienced or risks taken: “Some people your age who drink have school problems like lower grades or missed classes. Some do things and feel bad about them later, like damaging or stealing property, getting into fights, getting sexually involved, or driving or riding in a car driven by someone who has been drinking. Others get injured, have memory blackouts, or pass out. What not-so-good things related to drinking, if any, have you experienced?”
  • Ask about other substance use  (“Have you used anything else to get high in the past year?”) and consider using other formal tools to help gauge risk (see page 32). The majority of your lower risk patients will not have used illicit drugs (NIAAA, 2011), but ask them, too, about past-year use, time permitting.

Step 3: Advise and Assist

For patients who DO drink...

Lower Risk
Moderate Risk
Highest Risk
  • Provide brief advice: "I recommend that you stop drinking, and now is the best time. Your brain is still developing, and alcohol can affect that. Alcohol can also keep you from making good
    decisions and make you do things you’ll regret later. I would hate to see alcohol
    interfere with your future."

  • Notice the good: Reinforce any strengths and healthy decisions.
  • Explore and troubleshoot the potential influence of friends who drink or binge drink.
  • Does the patient have alcohol-related problems?
     - If no, provide beefed-up brief advice: : Start with
    the brief advice for Lower Risk patients (at left) and add your concern about the frequency of drinking. 
     - If yes, conduct brief motivational interviewing to elicit a decision and commitment to change (see page 29).
  • Ask if parents know: See suggestions for Highest Risk patients (at right).
  • Arrange for followup, ideally within a month.
  • Conduct brief motivational interviewing to elicit a decision and commitment to change, whether or not you plan to refer (see page 29).
  • Ask if parents know: : If so, ask patient permission to share recommendations
    with them. If not, take into account the patient’s age, the degree of acute risk posed, and other circumstances,
    and consider breaking
    confidentiality to engage parent(s) in follow-through.
  • Consider referral for further evaluation or treatment based on your estimate of severity (see page 23).
  • Arrange for followup within a month.
For All Patients Who Drink
  • Collaborate on a personal goal and action plan for your patient. Refer to page 31 for sample abstinence, cutting back, and contingency plans. For some patients, the goal will be accepting a referral to specialized treatment. 
  • Advise you patient not to drink and drive or ride in a car with an impaired driver.
  • Plan a full psychosocial interview for the next visit if needed.
If you observe signs of acute
danger, such as drinking
and driving, high intake
levels per occasion, or use
of alcohol with other drugs,
take immediate steps to
ensure safety (see page 21).

 

Step 4: At Followup, Continue Support

For patients who DO drink...

NO
<- Was patient able to meet -> and sustain goal(s)?YES

Patient was not able to meet and sustain goal(s):

  • Reassess the risk level (see Step 2 for drinkers).
  • Acknowledge that change is difficult; that it's normal not to succeed on the first try; and that reaching a goal is a learning process.
  • Notice the good by:
    -praising honesty and efforts
    -reinforcing strengths
    -supporting any positive change
  • Relate drinking to associated consequences or problems to enhance motivation.
  • Identify and address challenges and opportunities in reaching the goal.
  • If the following measures are not already underway, consider:
    -engaging the parents.
    -referring the patient for further evaluation.
  • Reinforce the importance of the goal(s) and plan and renegotiate specific steps, as needs.
  • Conduct, complete, or update the comprehensive psychosocial interview.

  • Reinforce and support continued adherence to recommendations.
  • Notice the good: Praise progress and reinforce strengths and healthy decisions.
  • Elicit future goal(s) to build on prior ones.
  • Conduct, complete, or update the comprehensive psychosocial interview.
  • Rescreen at least annually.