Reducing Stigma Through Conversations in Primary Care About Unhealthy Alcohol Use

Dear Editor,

We read with great interest the article by Bishop et al. on reducing stigma in primary care when addressing unhealthy alcohol use (1). As researchers in Family Medicine field, we wish to share our perspective on how these strategies resonate with experiences in Spain, particularly during the COVID-19 pandemic, and to discuss insights gained from our own work and from other authors in this field.

In many Spanish communities, alcohol consumption is deeply rooted in social and cultural contexts, which can create barriers to discussing related health risks in the primary care setting. The approach described by Bishop et al. aligns with growing evidence suggesting that universal screening, delivered as a routine part of every patient encounter, may help reduce stigma and encourage honest disclosure. Jonas et al. demonstrated that systematic screening followed by brief counseling can lead to significant reductions in harmful drinking patterns (2). In our clinical experience, patients are more likely to talk openly about their alcohol use when they perceive these questions as standard health inquiries rather than targeted interrogations. By normalizing the screening process, healthcare professionals convey a message of shared responsibility for identifying and addressing alcohol-related risks.

During the COVID-19 pandemic, the relevance of stigma reduction strategies became even more apparent. In Spain, repeated lockdowns and social distancing measures limited face-to-face consultations. Our practice quickly turned to telemedicine, a shift that challenged our usual methods of detecting problematic drinking. It is often through subtle, in-person observations, such as a patient’s demeanor, physical cues, or hesitations in conversation, that we uncover early signs of harmful alcohol use. Under pandemic conditions, these cues were harder to discern, which underscored the importance of explicit, non-judgmental questioning techniques. Moreover, studies have suggested that pandemic-related stress led some individuals to increase their alcohol consumption (3). From a primary care standpoint, teleconsultations proved quite valuable in sustaining care, yet we frequently encountered patients who felt uneasy discussing personal matters over the phone. Bishop et al. highlight the necessity of patient-centered language and motivational interviewing techniques; we confirm that these can still be successfully employed in remote interactions, provided clinicians receive adequate training and technical support.

The pandemic not only changed clinical interactions but also altered the environment in which support services functioned. As described in our own work (4), Alcoholics Anonymous and similar programs had to adapt quickly, turning physical meetings into virtual ones to maintain mutual aid networks. This emergency-driven transition was an instructive lesson on the value of digital platforms for maintaining the continuity of care and psychosocial support. However, the virtual modality was not a universal remedy. Vulnerable populations sometimes struggled with limited internet access or lacked the digital literacy required for videoconferencing tools. Others found the virtual environment insufficient for capturing the sense of fellowship that is central to the recovery process. These observations were echoed in Bishop et al.’s emphasis on patient-facing materials and communication strategies to normalize discussions about alcohol use. Traditional group settings offer an inherently non-stigmatizing environment where participants share challenges and coping strategies. Digital substitutes, while useful, can inadvertently isolate those who most need empathy and communal support.

In our own setting, once social restrictions were partially lifted, we adopted hybrid models of care, allowing patients to choose between remote or in-person consultations. This model helped mitigate some of the drawbacks of purely virtual visits. Similar experiences have been documented globally, where combining face-to-face encounters with telemedicine has offered flexibility and convenience without entirely losing the benefits of direct contact (5). From an epidemiological perspective, the World Health Organization’s guidelines for maintaining essential health services during public health crises underscored the importance of sustained interventions for non-communicable conditions, including alcohol use disorders (6). Integrating these recommendations in Spain required not only structural changes, such as reorganizing schedules and clinic spaces, but also reeducating clinical staff and patients about the continuing need to address alcohol-related concerns amid a pandemic.

We also wish to highlight the significance of collaborative care in reducing stigma. Bishop et al. mention patient-facing posters and informational materials. At our health center, we make a special effort to create infographic materials with QR codes that patients can scan while in the waiting room. These serve as supplementary resources to support explanations during medical consultations. One of these distributed culturally adapted infographic brochures explains why “we ask everyone” about alcohol use. Patients who might have felt singled out appreciated learning that these conversations were routine, objective, and aimed at improving overall health. Furthermore, when patients learned that our questions applied universally, they were more willing to consider brief interventions or referrals for counseling. These efforts echo evidence from Jonas et al. (2), which underlines that brief, consistent engagement between the clinician and the patient can reduce harmful drinking patterns.

Another core lesson relates to stigma within clinical teams themselves. Even among healthcare professionals, misconceptions about alcohol use can persist. Stressing that alcohol use disorder is a chronic condition, no different from hypertension or diabetes, has helped our teams approach the issue without judgment. In line with Bishop et al.’s findings, we integrated dedicated training sessions on motivational interviewing for both physicians and nursing staff. These sessions improved not only our communication skills but also team cohesion, as everyone recognized the shared objective of offering respectful and unbiased care.

Finally, looking ahead, we agree with Bishop et al.’s view that a community-based approach remains indispensable for sustaining progress. Spanish primary care historically has strong ties to local networks, including community centers and patient associations. By collaborating with these organizations, we can expand the reach of stigma reduction strategies. Tenajas et al. (4) emphasize how these community-driven efforts played a vital role in helping members of groups like Alcoholics Anonymous sustain their sobriety, particularly during periods of increased stress and isolation. Continued partnerships between clinics and support groups can ensure that those identified in screening have immediate access to resources for recovery, whether those are face-to-face meetings, virtual platforms, or hybrid formats.

In our opinion, the article by Bishop et al. offers valuable strategies for addressing unhealthy alcohol use in primary care by reducing stigma, normalizing universal screening, and promoting evidence-based communication. Our experiences in Spain, during and beyond the pandemic, confirm the importance of these steps and highlight the practical challenges of implementing them in evolving clinical environments. We hope our perspective will enrich ongoing discussions on this topic and foster more research on adapting these approaches to various cultural and health system contexts.

REFERENCES

1. Bishop D, Parsons D, Villalobos G, Bannon J, Rockwell M, Krist A, et al. Reducing Stigma Through Conversations in Primary Care About Unhealthy Alcohol Use. Ann Fam Med. 2025 Jan 1;23(1):83–83.

2. Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL, et al. Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012 Nov 6;157(9):645–54.

3. Kim JU, Majid A, Judge R, Crook P, Nathwani R, Selvapatt N, et al. Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. Lancet Gastroenterol Hepatol. 2020 Oct 1;5(10):886–7.

4. Tenajas R, Miraut D. The strength of connection: The virtual adaptation of Twelve-Step programs’ meetings. Front Health Inform. 2023;2023(12):1–3.

5. Galea S, Merchant RM, Lurie N. The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention. JAMA Intern Med. 2020 Jun 1;180(6):817–8.

6. World Health Organization. Maintaining essential health services: operational guidance for the COVID-19 context: interim guidance, 1 June 2020 [Internet]. [cited 2025 Mar 2]. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-essential-health-s...