Injury prevention/original research
Brief Intervention for Hazardous and Harmful Drinkers in the Emergency Department

Presented at the Society for Academic Emergency Medicine annual meeting, May 2005, New York, NY; and the Research Society on Alcoholism annual meeting, June 2005, Santa Barbara, CA.
https://doi.org/10.1016/j.annemergmed.2007.11.028Get rights and content

Study objective

To determine the efficacy of emergency practitioner–performed brief intervention for hazardous/harmful drinkers in reducing alcohol consumption and negative consequences in an emergency department (ED) setting.

Methods

A randomized clinical trial (Project ED Health) was conducted in an urban ED from May 2002 to November 2003 for hazardous/harmful drinkers. Patients 18 years or older who screened above National Institute for Alcohol Abuse and Alcoholism guidelines for “low-risk” drinking or presented with an injury in the setting of alcohol ingestion were eligible. The mean number of drinks per week and binge-drinking episodes during the past 30 days were collected at 6 and 12 months; negative consequences and use of treatment services, at 12 months. A Brief Negotiation Interview performed by emergency practitioners was compared to scripted Discharge Instructions.

Results

A total of 494 hazardous/harmful drinkers were studied. The 2 groups were similar with respect to baseline characteristics. In the Brief Negotiation Interview group, the mean number of drinks per week at 12 months was 3.8 less than the 13.6 reported at baseline. The Discharge Instructions group decreased 2.6 from 12.4 at baseline. Likewise, binge-drinking episodes per month decreased by 2.0 from a baseline of 6.0 in the Brief Negotiation Interview group and 1.5 from 5.4 in the Discharge Instructions group. For each outcome, the time effect was significant and the treatment effect was not.

Conclusion

Among ED patients with hazardous/harmful drinking, we did not detect a difference in efficacy between emergency practitioner–performed Brief Negotiation Interview and Discharge Instructions. Further studies to test the efficacy of brief intervention in the ED are needed.

Introduction

Alcohol problems are common in emergency department (ED) patients. In 2001, 7.6 million of the 110 million ED visits in the United States were attributable to alcohol.1 Alcohol has been shown to be a risk factor for injury and is involved in 40% of fatal motor vehicle crashes, 60% of fatal falls, 60% of suicides/homicides, and more than 60% of fire deaths in adults,2, 3 as well as a wide range of illnesses, including hypertension and gastrointestinal problems precipitating an ED visit.4 For population subgroups like the young and uninsured, the ED is often the primary access point to health care, and the ED visit may be the only opportunity for screening, intervention, and referral for alcohol problems. Unfortunately, alcohol screening and intervention is not widespread, so many patients with alcohol problems are not identified and treated.5

The spectrum of alcohol problems ranges from hazardous use to physical dependence. Hazardous or “at-risk” drinking is defined as drinking above the National Institute on Alcohol Abuse and Alcoholism low-risk guidelines: less than or equal to 14 drinks per week and less than or equal to 4 drinks per occasion for men, and less than or equal to 7 drinks per week and less than or equal to 3 drinks per occasion for women and all older than 65 years.6 Individuals who exceed these guidelines are at risk for future medical, social, or legal consequences. Harmful drinkers are those who present with negative consequence related to alcohol. Previous research conducted in primary care settings has demonstrated that hazardous and harmful drinkers may benefit from a one-time, brief intervention targeted at reducing alcohol use or its harmful effects.7, 8, 9

Brief interventions are counseling sessions ranging from 10 to 45 minutes, typically performed by nonaddiction specialists.10 Evidence suggests brief interventions are effective in primary care7 and inpatient trauma settings.11 Gentilello et al11 demonstrated that brief interventions provided to patients admitted to a trauma center were effective in significantly reducing alcohol consumption and decreasing repeated injury hospitalizations in patients who received interventions from a psychologist during their hospitalization after injury.

To date, few randomized controlled studies of brief interventions in the ED setting have been published.12, 13, 14, 15 All have concentrated on patients presenting with injuries, either older adolescents12 or adults,13, 14, 15 rather than general medical illnesses. In 3 studies, research staff performed the intervention,12, 13, 15 and in 1, the intervention was computer generated.14 The results varied. One observed a significant decrease in alcohol consumption in the intervention group,14 2 reported a similar decrease in alcohol consumption in the intervention and control groups but demonstrated significant reductions in negative consequences after the initial brief intervention session12 or a booster session13 in the intervention group, and 1 detected no difference in consumption between the intervention and control groups.15

The ED visit may present an opportunity for screening and brief intervention for hazardous and harmful drinking, yet unlike research in primary care settings, previous research on ED patients has not investigated the “real-life” scenarios of alcohol screening irrespective of presenting complaint, combined with brief interventions performed by emergency practitioners in an ED setting. This study assessed the efficacy of an emergency practitioner–performed intervention of less than 10 minutes in reducing alcohol consumption and negative consequences during 6- and 12-month periods.

Section snippets

Study Design and Setting

We conducted a randomized, controlled, clinical trial, comparing a brief (5 to 10 minutes), motivational intervention called the Brief Negotiation Interview,16 with scripted Discharge Instructions for hazardous and harmful drinkers, titled Project ED Health. Participants were enrolled between May 6, 2002, and November 12, 2003, after presenting to the ED of Yale–New Haven Hospital, a tertiary care urban hospital, with 70,000 annual adult ED visits. The study was approved by the Human

Results

The baseline demographic and health status characteristics of the subjects enrolled in this study appear in Table 1. The 2 groups were similar with respect to baseline characteristics. Additionally, the occurrence of an injury at ED presentation, alcohol use and problems as measured by AUDIT score, smoking status, or readiness to change did not differ significantly between the groups.

A flow diagram is provided in the Figure. A total of 250 patients were randomized to both Brief Negotiation

Limitations

There are a number of limitations to our study. First, we relied on self-report of alcohol consumption as the primary outcome measure. In an effort to decrease potential bias, researchers instructed patients to answer accurately, that there were no right or wrong answers, and that all information was confidential. In addition, questions about alcohol were embedded within other health screening questions at intake and telephone follow-up assessments. Self-report by telephone using Timeline

Discussion

Emergency practitioners performed a brief intervention for hazardous and harmful drinkers during the constraints of an ED visit. This study is unique in that it reports the feasibility of using existing clinical staff as opposed to research or ancillary counseling staff to perform an alcohol intervention and to include all eligible patients regardless of presenting complaint of injury or illness. However, the significant decrease in alcohol consumption at 6 months that persisted at the 12-month

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      Citation Excerpt :

      The theoretical underpinnings of the AB-CASI intervention are rooted in development and use of the Brief Negotiation Interview (BNI). Over the last 20 years, members of our study team and colleagues, have successfully developed, refined, and empirically tested the BNI in large clinical trials [31–33,60–63]. Originally developed with colleagues at Boston University in conjunction with Rollnick [64], the BNI has been improved over time and enhanced operationally to include 4 key components that include: 1) Raise the Subject of alcohol consumption; 2) Provide Feedback on the patient's drinking levels and effects; 3) Enhance Motivation to reduce drinking; 4) Negotiate and Advise a plan of action [63].

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    Supervising editor: David L. Schriger, MD, MPH

    Author contributions: All authors participated in the study design and interpretation of study data. GD, MVP, LCD, and PHO collected data. GD, DF, SHB, MCC, and PGO analyzed the data. GD, MCC, and PGO prepared the initial article draft. All authors critically reviewed the article, approved the final version, and participated in the decision to submit for publication. 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, 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. Funded by National Institute on Alcohol Abuse and Alcoholism grant R01 AA12417-01A1 (Dr. D'Onofrio), National Institute on Drug Abuse grant K23 DA15144 (Dr. Pantalon), and Robert Wood Johnson Generalist Physician Faculty Scholar Award (Dr. Fiellin).

    Publication date: Available online April 23, 2008.

    Reprints not available from the authors.

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