Brief Intervention and Referral to Treatment

1. Brief Intervention and Referral to Treatment EMERGENCY MEDICINE

2. Morbidity and Mortality • >107,000 alcohol related deaths each year • 1/3 of adult hospital admissions are alcohol related • Attributable risk factor for multiple illnesses • Major risk factor for all categories of injury • Problem drinkers have 2x injury events/yr and 4x as many hospitalizations for injury • A single alcohol-related visit predicts continued problem drinking • Social and family issues

3. Alcohol Related Injuries • 150,000 injury deaths in U.S. each year • several hundred thousand disabling injuries per year • 15-34 years olds at highest risk • alcohol use involved in large proportion of deaths and injuries

4. Alcohol Related Costs • Medical treatment, insurance, unemployment, lack of productivity • Families with an alcoholic member have twice the average monthly health care bill than other families

5. Alcohol Related Casualties • Under reported on death certificates • Under reported on hospital discharge • Selection and recording bias

8. Alcohol-Related Fatalities in MVCs Source: FARS

9. BAC Levels for Alcohol Positive Drivers Involved in Alcohol-Related Fatal Crashes .16 = Median and Mode BAC Source: 2002 ARF FARS

10. Drinking Patterns in the U. S. Abstain 40% Dependent 5% At Risk or Problem 20% Low Risk 35% Source: National Longitudinal Alcohol Epidemiologic Survey, 1992

11. Prevention and Intervention MODERATE (20%) at risk drinkers SEVERE (10%) ABSTAINERS & MILD DRINKERS (70%) Specialized Treatment Brief Intervention Primary Prevention

12. Alcohol Terminology • Hazardous drinking - at-risk drinking • NIAAA definition • Harmful drinking • Health consequences • Binge drinking • 5 or more drinks per drinking episode

13. Alcohol Terminology • Dependence - cluster of symptoms including impaired control over intake, withdrawal symptoms, tolerance, drinking despite problems • Abuse - repetitive patterns of drinking in harmful situations with adverse consequences, including impaired ability to fulfill responsibilities or negative effects on social/interpersonal functioning and health

14. Issues related to lack of exploration of alcohol use • Lack of understanding of problem • Failure to acknowledge responsibility for identification/intervention • Biases - personal/professional • Feeling that nothing can be done • Not knowing what can be done • Outside of what is thought to be the traditional realm of medical care providers

15. Issues Related to ED Provider Screening for Alcohol Use • Alcohol screening not traditionally part of physician job • Not comfortable with alcohol related issues • Don’t know how to intervene • Frustration over prior experiences with patients who abuse alcohol

16. Alcohol Use as Part of the Medical History • Alcohol use • Quantity • Frequency • Type of alcohol used • Problems related to alcohol use

17. Alcohol Screening - Issues • Not seen as responsibility of physician in ED • Included as part of “social” history • Providers not educated concerning importance of alcohol screening as routine practice • Providers not educated concerning how to ask the questions

18. Alcohol Interventions • Brief intervention • Further evaluation and more extensive intervention for person with more significant problem • Provider intervention may be more effective

19. Social Morays

20. A Standard Drink A standard drink is 12 grams of pure alcohol or: • One 12-ounce bottle of beer or wine cooler • One 5-ounce glass of wine • 1.5 ounces of distilled spirits

21. Screen Positive

22. Drinking Patterns: Rates and Risks Binge Drinking The National Advisory Council on Alcohol Abuse and Alcoholism has recommended the following definition of “Binge Drinking”: • A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gm% or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male) or 4 or more drinks (female) in about 2 hours. • Binge drinking is clearly dangerous for the drinker and for society

23. Brief Intervention • Short counseling sessions (5-45 minutes) • Single or repeated sessions • Performed by non-addiction specialists • Contain advice and/or motivational enhancement

24. Brief Intervention • At risk/problem drinkers • Advise to cut down • Set goals • Provide Primary Care follow-up • Dependence • Advise to abstain • Refer to treatment

25. Advise: What? • ABSTAIN • pregnant or considering • medication that interacts • dependence • failed attempts to cut down • contraindicated medical condition • CUT DOWN • drinking above low risk amounts • no dependence • no problems

26. Stages of Change Model Pre-Contemplation Contemplation Maintenance Preparation Action Prochaska & DiClemente, 1986

27. General Principles for Negotiating Behavior Change • Respect for autonomy of patients and their choices • Readiness to change must be taken into account • Ambivalence is common • Targets selected by the patient, not the expert • Expert is the provider of the information • Patient is the active decision-maker Rollnick, 1994