General medicine/original research
A Brief Intervention Reduces Hazardous and Harmful Drinking in Emergency Department Patients

Presented at the Society for Academic Emergency Medicine annual meeting, June 2010, Phoenix, AZ; and the International Society for Biomedical Research on Alcoholism, September 2010, Paris, France.
https://doi.org/10.1016/j.annemergmed.2012.02.006Get rights and content

Study objective

Brief interventions have been shown to reduce alcohol use and improve outcomes in hazardous and harmful drinkers, but evidence to support their use in emergency department (ED) patients is limited. The use of research assessments in studies of brief interventions may contribute to uncertainty about their effectiveness. Therefore we seek to determine (1) if an emergency practitioner-performed Brief Negotiation Interview or a Brief Negotiation Interview with a booster reduces alcohol consumption compared with standard care; and (2) the impact of research assessments on drinking outcomes using a standard care-no-assessment group.

Methods

We randomized 889 adult ED patients with hazardous and harmful drinking. A total of 740 received an emergency practitioner–performed Brief Negotiation Interview (n=297), a Brief Negotiation Interview with a 1-month follow-up telephone booster (Brief Negotiation Interview with booster) (n=295), or standard care (n=148). We also included a standard care with no assessments (n=149) group to examine the effect of assessments on drinking outcomes. Primary outcomes analyzed with mixed-models procedures included past 7-day alcohol consumption and 28-day binge episodes at 6 and 12 months, collected by interactive voice response. Secondary outcomes included negative health behaviors and consequences collected by telephone surveys.

Results

The reduction in mean number of drinks in the past 7 days from baseline to 6 and 12 months was significantly greater in the Brief Negotiation Interview with booster (from 20.4 [95% confidence interval {CI} 18.8 to 22.0] to 11.6 [95% CI 9.7 to 13.5] to 13.0 [95% CI 10.5 to 15.5]) and Brief Negotiation Interview (from 19.8 [95% CI 18.3 to 21.4] to 12.7 [95% CI 10.8 to 14.6] to 14.3 [95% CI 11.9 to 16.8]) than in standard care (from 20.9 [95% CI 18.7 to 23.2] to 14.2 [95% CI 11.2 to 17.1] to 17.6 [95% CI 14.1 to 21.2]). The reduction in 28-day binge episodes was also greater in the Brief Negotiation Interview with booster (from 7.5 [95% CI 6.8 to 8.2] to 4.4 [95% CI 3.6 to 5.2] to 4.7 [95% CI 3.9 to 5.6]) and Brief Negotiation Interview (from 7.2 [95% CI 6.5 to 7.9] to 4.8 [95% CI 4.0 to 5.6] to 5.1 [95% CI 4.2 to 5.9]) than in standard care (from 7.2 [95% CI 6.2 to 8.2] to 5.7 [95% CI 4.5 to 6.9] to 5.8 [95% CI 4.6 to 7.0]). The Brief Negotiation Interview with booster offered no significant benefit over the Brief Negotiation Interview alone. There were no differences in drinking outcomes between the standard care and standard care–no assessment groups. The reductions in rates of driving after drinking more than 3 drinks from baseline to 12 months were greater in the Brief Negotiation Interview (38% to 29%) and Brief Negotiation Interview with booster (39% to 31%) groups than in the standard care group (43% to 42%).

Conclusion

Emergency practitioner–performed brief interventions can reduce alcohol consumption and episodes of driving after drinking in hazardous and harmful drinkers. These results support the use of brief interventions in ED settings.

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)

  • P.G. O'Connor et al.

    Patients with alcohol problems

    N Engl J Med

    (1998)
  • C. Cherpitel

    Drinking patterns and problems: a comparison of primary care with the emergency room

    Subst Abuse

    (1999)
  • G. D'Onofrio et al.

    Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review

    Acad Emerg Med

    (2002)
  • M.L. Willenbring et al.

    Helping patients who drink too much: an evidence-based guide for primary care clinicians

    Am Fam Physician

    (2009)
  • R.M. Cunningham et al.

    Alcohol, tobacco, and other drugs: future directions for screening and intervention in the emergency department

    Acad Emerg Med

    (2009)
  • M.C. Reid et al.

    Hazardous and harmful alcohol consumption in primary care

    Arch Intern Med

    (1999)
  • O. Nilssen

    Long-term effect of brief intervention in at-risk alcohol drinkers: a 9-year follow-up study

    Alcohol Alcohol

    (2004)
  • E.F.S. Kaner et al.

    Effectiveness of brief alcohol interventions in primary care populations

    Cochrane Database Syst Rev

    (2007)
  • L.I. Solberg et al.

    Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness

    Am J Prev Med

    (2008)
  • L.M. Gentilello et al.

    Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis

    Ann Surg

    (2005)
  • J.B. Daeppen et al.

    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

    (2007)
  • G. D'Onofrio et al.

    Brief intervention for hazardous and harmful drinkers in the emergency department

    Ann Emerg Med

    (2008)
  • R. Longabaugh et al.

    Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department

    J Stud Alcohol

    (2001)
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      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

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    Publication date: Available online March 28, 2012.

    Provide feedback on this article at the journal's Web site, www.annemergmed.com.

    A podcast for this article is available at www.annemergmed.com.

    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.

    1

    Dr. Degutis is now at Centers for Disease Control and Prevention, Atlanta, GA.

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