Brief intervention helps emergency patients reduce drinking

Asking emergency department patients about their alcohol use and talking with them about how to reduce harmful drinking patterns is an effective way to lower rates of risky drinking in these patients, according to a nationwide collaborative study supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

Emergency department patients who underwent a regimen of alcohol screening and brief intervention reported lower rates of risky drinking at three-month follow-up than did those who received only written information about reducing their drinking. A report of the study by the Academic Emergency Department Screening, Brief Intervention and Referral to Treatment (SBIRT) Research Collaborative* appears in the December, 2007 issue of the Annals of Emergency Medicine.

“This encouraging finding raises the prospect of reaching many individuals whose alcohol misuse might otherwise go untreated,” says NIAAA Director Ting-Kai Li, M.D.

“These new findings underscore the importance of using the American Medical Association health care codes for substance abuse screening and brief intervention,” said SAMHSA Administrator Terry Cline, Ph.D.

Codes established by the AMA serve as the most widely accepted classification system for reporting medical procedures and services to public and private health insurance programs. In January, 2008 new codes will allow physicians to report services they provide to screen patients for alcohol problems and to provide a behavioral intervention for high-risk drinking.

“Using these new codes will increase the likelihood that an estimated 18.8 million Americans with serious alcohol abuse problems will receive effective intervention services that could possibly save their lives and promote wellbeing,'' adds Dr. Cline.

Previous studies of screening, brief intervention, and referral conducted in primary care and in-patient trauma centers have shown positive outcomes in decreasing or eliminating alcohol use, reducing injury rates, and reducing costs to society.

In the current study, investigators at 14 university-based emergency centers throughout the United States used a brief questionnaire to assess the alcohol use patterns of 7,751 emergency patients, regardless of whether they had signs of alcohol use on admission. They found that more than one-fourth of the patients exceeded the limits for low-risk drinking -- defined by NIAAA as no more than: four drinks per day for men and three drinks per day for women; and not more than 14 drinks per week for men, and seven drinks per week for women. More than 1,100 patients who exceeded these limits agreed to continue to participate in the study and were divided into intervention and control groups. The study enrolled patients with all levels of risky drinking and visit type.

The primary intervention consisted of a Brief Negotiated Interview (BNI) that emergency practitioners performed with each member of the intervention group. Patients in the intervention group also received a written handout explaining low-risk drinking and a referral list of alcohol treatment providers. Patients in the control group received only the low-risk drinking handout and referral list.

More than 400 emergency department providers including physicians, nurses, social workers, nurse practitioners and physician's assistants were trained in the BNI in either a two-hour interactive workshop or via the Internet.

"The BNI, a conversation between emergency care providers and patients that involves listening rather than telling, and guiding rather than directing, is designed to review the patient's current drinking patterns, assess their readiness to change, offer advice about the low-risk guidelines and the next steps to pursue, and negotiate a written prescription for change or a drinking agreement with the patient," explains co-author Edward Bernstein, M.D., professor and vice chair for academic affairs in the department of emergency medicine at Boston University School of Medicine. Dr. Bernstein, who coordinated the training of emergency department personnel in the study, notes that the interview typically takes less than 10 minutes to complete.

Researchers contacted members of each group three months later to assess any changes in drinking habits. The intervention group reported drinking three fewer drinks per week than the controls, and more than one-third of individuals in the intervention group reported drinking at low-risk levels, compared with about one-fifth of those in the control group.

“This study demonstrates that a broad group of emergency practitioners can learn how to perform the intervention and that it is effective across multiple practice sites,” says co-author Gail D'Onofrio, M.D., professor and chief of emergency medicine at Yale University. “The emergency department visit is often the only access to care for many patients and thus is an ideal opportunity to begin the conversation regarding unhealthy alcohol use.”

The researchers conclude that widespread use of these techniques by emergency personnel could significantly reduce unhealthy alcohol use.

“Our results should provide the impetus for broader implementation of screening, brief intervention, and referral for treatment in the emergency department setting,” notes co-author Robert Aseltine, Ph.D., associate professor in the division of behavioral science and community health and director of the Institute for Public Health Research at the University of Connecticut Health Center.