Reducing Stigma Through Conversations in Primary Care About Unhealthy Alcohol Use

THE INNOVATION

The Agency for Healthcare Research and Quality (AHRQ) launched the national EvidenceNOW: Managing Unhealthy Alcohol Use in Primary Care initiative in 2019. The initiative funded 6 grantees across the United States to implement screening, brief intervention, and referral to treatment (SBIRT) and medication-assisted therapy/medication for alcohol use disorder (MAT/MAUD) to manage unhealthy alcohol use (UAU) by patients in primary care practices. Grantees quickly learned that it was imperative to address stigma to effectively implement SBIRT/MAT/MAUD. Grantees developed both clinician-facing and patient-facing materials to reduce stigma and better serve patients who demonstrate risky or harmful alcohol use.

WHO & WHERE

Grantees provided SBIRT and MAT/MAUD implementation assistance in small and medium-size primary care practices, and larger primary care systems in rural, suburban, and urban areas serving diverse patients. Grantees utilized practice facilitators (PFs) to recruit practices, provide training, support implementation, and assist with data collection. Practice facilitators were instrumental in working with practices to incorporate stigma reduction strategies to facilitate the implementation of SBIRT/MAT/MAUD.

HOW

Normalizing alcohol screening is a key strategy for reducing stigma. Grantees helped clinicians to integrate universal and routine unhealthy alcohol use (UAU) screening into their workflow and educate patients that providers screen everyone.

To support clinicians in implementing universal screening, PFs offered training, coaching, and guides on talking with patients about UAU. Trainings addressed common pitfalls (stigma, labeling, discrimination, and privacy concerns) and helped clinicians feel more comfortable facilitating such conversations. PFs modeled appropriate language and tone with patients and trained practice staff on motivational interviewing skills to address alcohol consumption habits in collaborative vs judgmental ways. With training videos, 1:1 meetings, and materials, PFs provided guidance on utilizing person-centered language (eg, person with an alcohol use disorder vs alcoholic/addict) and demonstrated how to communicate with respect and empathy. PFs provided tools, handouts, and visual aids for administering screenings and discussing UAU with patients. PFs also collaborated with practices on developing scripts to guide conversations. Reminding clinicians that alcohol use disorder is a chronic condition helped reduce stigma toward struggling patients. This combination of training, implementation support, and materials helped clinicians feel more comfortable having conversations and connecting patients to additional care if needed.

To reduce stigma among patients, PFs provided materials to notify patients that their practice asks about alcohol use at least annually to improve their quality of care. This information reduced the likelihood that patients could feel targeted or stigmatized and conveyed that they could feel comfortable talking to their clinician about alcohol use. One grantee developed a “We Ask Everyone” poster comparing UAU screening to other preventive screenings such as colon and depression.

LEARNING

Several key factors helped clinicians reduce stigma around having conversations about UAU, including utilizing flexibility in responding to practice needs (eg, offering in-person, virtual, or hybrid training options), engaging a practice champion, and providing patient-facing posters, handouts, and scripted language. Celebrating the achievement of small goals (eg, increases in SBIRT rates, success stories from patients) reminded practices that their efforts to reduce stigma were helping patients and motivated them to continue even amidst patient setbacks. With these techniques, trainings, and materials, PFs helped practices cultivate a culture of universal screening, which normalized the discussion for both clinicians and patients, thereby reducing stigma.