General medicine/original researchA Brief Intervention Reduces Hazardous and Harmful Drinking in Emergency Department Patients
Introduction
Alcohol problems are prevalent in emergency department (ED) populations.1, 2 Individuals may seek medical care for acute illness and injury related to alcohol or are identified through universal screening.3, 4, 5, 6, 7, 8, 9 These individuals often receive their care in EDs in lieu of primary care settings,10 resulting in significant health care costs.1, 11 Hazardous and harmful drinking,12 consuming greater than 14 drinks per week or greater than 4 drinks per occasion for men, and greater than 7 drinks per week or greater than 3 drinks per occasion for women and all individuals older than 65 years, with or without negative consequences, is a major focus of screening, brief intervention, and referral to treatment efforts in health care settings.13, 14, 15
Evidence exists for the usefulness of brief interventions for alcohol in primary care16, 17, 18 and inpatient trauma settings.19 The data in ED settings are less clear. Although consumption decreases over time,20, 21, 22, 23, 24 few studies have identified benefits specific to brief interventions in ED patients. A recent meta-analysis of strategies targeting alcohol problems in the ED found that brief interventions did not significantly reduce drinking but were associated with a 50% reduction in alcohol-related injury.25 Methodological heterogeneity across studies makes it difficult to draw conclusions concerning the efficacy of brief interventions in ED patients.26 Differences in screening tools, application to universal or injured-only populations, the targeting of the intervention from at-risk to dependence drinkers, and variation in measures or definitions make it difficult to compare studies.27 There is an additional concern that research assessments of alcohol consumption can themselves lead to decreased drinking,28 thus making it difficult to separate the assessment effect from the overall intervention outcomes.
We conducted a study designed to evaluate the efficacy of a brief intervention, the Brief Negotiation Interview, and to address the concern of a research assessment effect. We hypothesized that in hazardous and harmful drinkers, both past 7-day alcohol consumption and binge episodes during the past 28 days would be reduced most in an enhanced Brief Negotiation Interview with a 1-month booster (Brief Negotiation Interview with booster) condition compared with Brief Negotiation Interview alone or a standard care control condition and that the Brief Negotiation Interview would be superior to standard care. Additionally, we hypothesized that the Brief Negotiation Interview with booster and Brief Negotiation Interview would be superior to standard care in reducing negative health behaviors and consequences. Finally, we hypothesized that assessments reduce drinking and thus added a nonassessed standard care group (standard care–no assessment) to evaluate the effect of assessments.
Section snippets
Study Design
We conducted a randomized clinical trial comparing the efficacy of standard care with the Brief Negotiation Interview performed by emergency practitioners and the Brief Negotiation Interview with booster with a nurse-performed booster telephone call at 1-month. To reduce or eliminate the potential social desirability bias in reporting alcohol consumption, the primary outcomes in the Brief Negotiation Interview, Brief Negotiation Interview with booster, and standard care groups were evaluated at
Characteristics of Study Subjects
The baseline characteristics of randomized subjects (N=889) are shown in Table 1. The groups were similar on all of the baseline characteristics.
All participants randomized to the Brief Negotiation Interview, Brief Negotiation Interview with booster, and standard care groups received treatment as assigned, and 81% of the Brief Negotiation Interview with booster subjects received the booster. The proportions of patients completing interactive voice response assessment at 6 months were 179 of 297
Limitations
This study was conducted at 1 site: a teaching hospital associated with an academic institution. However, we were able to train a large number of emergency practitioners with a variety of training and experience. To demonstrate efficacy of the intervention, high levels of treatment and study protocol adherence are essential and can best be accomplished at 1 site. Although our data are based on self-report, we used a reliable timeline follow-back method34 to collect alcohol consumption data. We
Discussion
Emergency practitioner–performed brief interventions for hazardous and harmful drinkers significantly reduced alcohol consumption and decreased impaired driving. Contrary to our hypothesis, the booster offered no additional benefit, demonstrating that a brief intervention performed solely with existing staff, during a visit to a large urban ED setting, can be effective. The greater reductions from baseline to 12 months in mean number of drinks per week in the Brief Negotiation Interview with
References (47)
- et al.
Assessing substance abuse treatment need: a statewide hospital emergency department study
Ann Emerg Med
(2003) - et al.
Reducing harm from alcohol: call to action
Lancet
(2009) - et al.
Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later
Drug Alcohol Depend
(2009) - et al.
A systematic review of emergency care brief alcohol interventions for injury patients
J Subst Abuse Treat
(2008) - et al.
US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000
Arch Intern Med
(2004) - et al.
Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO
Arch Intern Med
(2003) - et al.
The role of alcohol use in emergency department episodes
Subst Use Misuse
(2008) - et al.
Alcohol-attributable fraction for injury in the US general population: data from the 2005 National Alcohol Survey
J Stud Alcohol Drugs
(2008) Alcohol and injuries: a review of international emergency room studies since 1995
Drug Alcohol Rev
(2007)- et al.
Correlates of injury among ED visits: effects of alcohol, risk perception, impulsivity, and sensation seeking behaviors
Am J Drug Alcohol Abuse
(2007)
Patients with alcohol problems
N Engl J Med
Drinking patterns and problems: a comparison of primary care with the emergency room
Subst Abuse
Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review
Acad Emerg Med
Helping patients who drink too much: an evidence-based guide for primary care clinicians
Am Fam Physician
Alcohol, tobacco, and other drugs: future directions for screening and intervention in the emergency department
Acad Emerg Med
Hazardous and harmful alcohol consumption in primary care
Arch Intern Med
Long-term effect of brief intervention in at-risk alcohol drinkers: a 9-year follow-up study
Alcohol Alcohol
Effectiveness of brief alcohol interventions in primary care populations
Cochrane Database Syst Rev
Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness
Am J Prev Med
Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis
Ann Surg
Brief alcohol intervention and alcohol assessment do not influence alcohol use in injured patients treated in the emergency department: a randomized controlled clinical trial [published correction appears in Addiction. 2007;102:1995]
Addiction
Brief intervention for hazardous and harmful drinkers in the emergency department
Ann Emerg Med
Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department
J Stud Alcohol
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2023, Annals of Emergency MedicineCitation Excerpt :There are some established evidence-based practices and recommendations for initiatives aimed to improve care for ED patients with substance use disorders. Current research supports using screening, brief intervention, and referral for treatment for patients with unhealthy alcohol use in the ED.11-14 For patients with opioid use disorder, there is increasing support for starting medications for opioid use disorder in the ED and distributing naloxone for patients at risk of overdose.6,15
Publication date: Available online March 28, 2012.
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Supervising editor: Debra E. Houry, MD, MPH
Author contributions: All authors conceived the study, participated in study design, assisted in obtained funding, and contributed to interpretation of the data. GD and PHO provided administrative and technical or material support and were responsible for acquisition of the data and overall study supervision. MCC analyzed the data. GD and PGO drafted the article and all authors participated in its critical revision. GD takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Funded by National Institute on Alcohol Abuse and Alcoholism grant 1R01AA14963.
Please see page 182 for the Editor's Capsule Summary of this article.
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Dr. Degutis is now at Centers for Disease Control and Prevention, Atlanta, GA.