INJURY PREVENTION/ORIGINAL RESEARCHThe Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patients' Alcohol Use
Introduction
Unhealthy alcohol use, ranging from at-risk drinking to dependence, is a leading cause of morbidity, mortality, and cost in the United States.1, 2, 3, 4, 5, 6, 7, 8 There is substantial evidence from primary care settings that brief interventions with at-risk drinkers reduce alcohol abuse, increase treatment contact, and are cost effective.9, 10, 11, 12 Despite the high prevalence, morbidity, and mortality of alcohol-related emergency department (ED) visits,13, 14, 15, 16, 17, 18, 19 brief intervention techniques have not been tested widely in EDs. Health care providers confront the consequences of alcohol abuse daily but often lack the skills to engage patients in health-promoting behavior change.20, 21
Recent studies offer encouraging evidence concerning the efficacy of brief interventions in the ED setting when performed by a variety of non-ED providers.22, 23, 24, 25, 26 Hospital EDs offer a teachable moment to address the consequences of unhealthy alcohol use across the entire spectrum of severity and effect a behavior change that could improve patient outcomes, especially among those whose visit was alcohol related.22, 25, 26 However, the effectiveness of brief interventions delivered by ED providers themselves has not yet been clearly demonstrated.
We sought to determine the effectiveness of ED provider–initiated Screening, Brief Intervention, and Referral to alcohol Treatment (SBIRT) to reduce alcohol consumption among patients reporting unhealthy levels of alcohol use.
Section snippets
Study Design
A quasiexperimental comparison group design was used to evaluate the effectiveness of SBIRT in the ED setting.27 Participants assigned to the control group received screening for at-risk drinking and a written list of referral resources. On completion of a standardized 2-hour educational curriculum based on work at Boston Medical Center and Yale University,23, 28, 29 trained ED providers delivered the brief intervention, namely, the Brief Negotiated Interview, to participants during the
Results
A total of 402 ED staff members were trained in the Brief Negotiated Interview: 60% were physicians (attending physicians and residents), 21% nurses, 7% physician extenders (physician assistants and advanced practice nurses), and 12% social workers and EMTs. Forty-nine percent of all Brief Negotiated Interviews provided to patients were delivered by physicians, 19% by nurses, 19% by physician extenders, and 10% by social workers and EMTs.
Screening and enrollment results are presented in Figure 2
Limitations
This study has several limitations. We used a quasiexperimental design that was randomized only by time sequence, not within time sequence. This design was chosen in an effort to minimize the threat of contamination attributable to the training of ED staff in the Brief Negotiated Interview before the enrollment of controls, which we deemed a much greater threat to validity than the absence of randomization within each period. Also, patient recruitment was limited by the availability of research
Discussion
Brief interventions by primary care providers have been shown to be an efficacious and cost-effective modality for eliminating or reducing harmful health behaviors related to alcohol abuse.12, 49, 50, 51, 52 However, these techniques are used infrequently by ED staff, despite a substantial number of patients with alcohol problems.38, 53 The current multicenter study is the first to demonstrate efficacy of an ED provider intervention across a diverse group of ED practices, clinicians, and
References (58)
Screening for alcohol problems in the emergency department
Ann Emerg Med.
(1995)- et al.
Intoxicated ED patients: a five year follow-up of morbidity and mortality
Ann Emerg Med.
(1997) - et al.
Project ASSERT: an ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system
Ann Emerg Med.
(1997) - et al.
Evaluation of a brief intervention in an inner-city emergency department
Ann Emerg Med
(2005) - et al.
Correspondence between interactive voice response (IVR) and timeline followback (TLFB) reports of drinking behavior
Addict Behav
(2006) - et al.
Improving emergency residents' approach to patient with alcohol problems: a controlled educational trial
Acad Emerg Med
(2002) - et al.
Brief intervention in a primary care setting for hazardous drinkers
Am J Prev Med
(1997) - et al.
Screening and referral for brief intervention of alcohol misusing patients in an emergency department: a pragmatic randomized controlled trial
Lancet
(2004) Clinical practiceUnhealthy alcohol use
N Engl J Med
(2005)- National Institute on Alcohol Abuse and Alcoholism. Ninth Special Report to the U.S. Congress on Alcohol and Health....
Actual causes of death in the United States
JAMA
National Survey Results on Drug Use from the Monitoring the Future Study, 1999
Brief physician advice for problem drinkers: long term efficacy and benefit-cost analysis
Alcohol Clin Exp Res.
The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review
Addiction.
Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers
J Gen Intern Med.
Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis
Arch Intern Med
National Hospital Ambulatory Medical Care Survey: 2000 emergency department summary
Adv Data.
Alcoholism in the emergency department
Acad Emerg Med.
Emergency department detection and referral rates for patients with problem drinking
Subst Abuse.
Behavioral risk factors in emergency department patients: a multi-site survey
Acad Emerg Med.
Drinking patterns and problems: a comparison of primary care with the emergency room
Subst Abuse.
Emergency physician attitudes concerning intervention for alcohol abuse/dependence delivered in the emergency department: a brief report
J Addict Dis
Knowledge, attitudes and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism
JAMA
The efficacy of two brief intervention strategies among injured, at-risk drinkers in the emergency department: impact of tailored messaging and brief advice
J Stud Alcohol
Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department
J Stud Alcohol
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2022, Journal of Substance Abuse TreatmentCitation Excerpt :Non-medical models like screening, brief intervention, and referral to treatment (SBIRT) have sought to mitigate the treatment gap by identifying ED patients with substance use disorders, providing brief therapeutic contact, and referring the most severe cases to longer-term care. While some SBIRT programs have shown promising effects on post-ED engagement in substance use treatment (Krupski et al., 2010), results have been mixed, and most research has focused on SBIRT for patients with alcohol use disorder (Academic ED SBIRT Research Collaborative, 2007; Blow et al., 2006; Crawford et al., 2004; Estee et al., 2010; Monti et al., 2007; Neumann et al., 2006; Spirito et al., 2004). Brief motivational interventions appear somewhat less effective at engaging drug-dependent patients in long-term treatment (Bernstein et al., 2005; Donovan et al., 2001; Rapp et al., 2008; Tait et al., 2004) or modifying their drug use (Bogenschutz et al., 2014; Marsden et al., 2006; Miller et al., 2003; Stein et al., 2009), and positive effects tend to deteriorate over time (McCambridge & Strang, 2005).
Supervising editor: David. L. Schriger, MD, MPH
Author contributions: EB, GD, JB, and RHA conceived the study and obtained the initial funding for the development of the curriculum and the training (R25), and RHA for the Data Coordinating Center (R21). All sites submitted (RO3s) for patient outcomes and participated in data collection. RHA analyzed the data. All authors participated in the interpretation of the data. EB, JB, GD, and RHA participated in drafting the article. All authors participated in the critical review of the article. EB, JB, GD, and RHA take 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, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Funding was provided by the National Institute of Alcohol Abuse and Alcoholism 1R25AA014957 (E. Bernstein, J. Bernstein, and G. D'Onofrio); 1R03AA01511-14 (all site authors); R21 AA015123 (R. H. Aseltine).
Reprints not available from the authors.
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All members are listed in Appendix 1.