The Rationale for Screening, Brief Intervention and Referral in the Medical Setting

1. The Rationale for Screening, Brief Intervention and Referral in the Medical Setting

2. WHY EARLY INTERVENTION FOR HIGH-RISK AND DEPENDENT DRINKING? • High-risk and dependent drinking reduces quality and length of life, and is costly to individuals and society. • The medical encounter is too important a prevention opportunity to miss. • Physician feedback & advice is a powerful motivator. • Intervention results in improved prognosis. • Intervention reduces ED utilization & cost.

3. Alcohol & Other Drug Dependence, A Chronic Illness • <30% of patients with adult onset asthma, HTN, diabetes adhere to prescribed diet and/or behavioral changes • 50% of adults with these chronic conditions experience recurrence of sx yearly, requiring additional medical care • 50-60% of patients discharged from substance abuse treatment are abstinent at 1 year • As in other chronic diseases, poor adherence and relapse is predicted by low SES, co-morbid psych conditions and lack of family and social supports • Substance abuse should be insured, monitored, treated and evaluated like other chronic diseases McClellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.

4. Health Care Settings UsingBrief Motivational Intervention • Trauma Centers • Emergency Departments • General Medical Practice • Family Medicine & Primary Care • Pediatrics & Adolescent Medicine • Inpatient Consult Service • Oral and Maxillofacial Surgery • Psychiatric Services • Student Health Centers • Physical Medicine and Rehabilitation

5. Public Health Paradigm The primary goal of brief intervention is to • reduce alcohol use to low-risk levels • encourage abstinence in persons who are alcohol-dependent

6. BRIEF INTERVENTION: A REVIEW • Chafetz et al, 1961 • Randomized, controlled trial (n=200) • 65% of those receiving brief intervention in the MGH ED kept a subsequent appointment for specialized treatment compared to 5% of controls. • 40% kept 5 appointments. (Establishing treatment relations with alcoholics. J Nerv Ment Dis 1962; 134: 390-410.)

7. ALCOHOL TREATMENT WORKS • McClellan (1982) showed treatment effects at 6 months f/u on ASI measures of alcohol use, drug use, family interactions, work, legal and psychological function • 54% reduction in drinking days • 67% reduction in days intoxicated • 41% of participants abstinent for 30 days prior to follow-up • 151% increase in income McClellan TA, Luborsky L, O’Brien CP, et al. Is treatment for substance abuse effective? JAMA 1982; 247:1423-1428.

8. BRIEF INTERVENTION: A REVIEW • Bien TH, Miller WR, Tonigan JS, 1993 • meta-analysis (n=6000)13 randomized trials; 32 controlled trials • more effective than no counseling • as effective as traditional therapy in 11/13 trials Brief intervention for alcohol problems: A review. Addiction 1993; 88: 315-335.

9. Alcohol Intervention in a Trauma Center to Reduce Injury Recurrence • Randomized, controlled trial • Level 1 Trauma Center patients screened with blood alcohol , GGT, and Michigan Alcoholism Screening Test (SMAST) • 772 positives randomized to intervention or control • Re-injury detected by computer search of statewide ED and hospital discharge records • Alcohol use assessed at 6 and 12 months Gentilello, Rivara et al. Ann Surg 1999; 230: 473-483

10. Trauma Center Results • 1153 (46%) of 2524 screened positive • intervention n = 366 vs control n = 396 • at 6 months, decreases in both groups (NS) • at 12 months, reduced alcohol consumption • down by 22 drinks per week in intervention group • down 6.7 drinks per week in control group • reduced number of injuries requiring ED or admission • down 47% in the intervention group vs controls Gentilello, Rivara et al. Ann Surg 1999; 230: 473-483

11. D’Onofrio & Degutis (Acad Emerg Med) • Review of 39 clinical trials • 30 (RCT) • 9 (Cohort) • 32 studies reveal positive effect of BI

12. Brief Intervention for Harm Reduction With Alcohol + Older Adolescents in a Hospital ED • Population: 18 to 19 year olds (n = 94) • Site: Rhode Island Hospital PED • Intervention: motivational intervention by masters level practitioners, primarily social workers • Outcomes: alcohol consumption, drinking and driving, alcohol related problems, injuries, moving violations (DMV) • Design: RCT with 3 and 6 month f/u Monti P, et al. J Consult Clin Psychol 1999; 67:989-994.

13. Monti et al. Results of Brief Motivation with Adolescent ED Patients • Follow-up rate: 93% at 3 months, 89% at 6 months • Moving violations: 3% in the intervention group vs 26% in the control group • Similar reductions in alcohol use despite differences in alcohol related consequences • having driven after drinking ( p<0.05) • having had alcohol involved in an injury (p<0.01) • to have had alcohol-related problems (p<0.05)

14. Evaluating the effects of a brief motivational intervention for injured drinkers in the ED. Longabaugh R, Woolard RE, Nirenberg TD, et al. J Stud Alcohol 2001 • n=539 injured ED patients with an AUDIT score of >8 or alcohol in system at the time of injury • 1 year f/u = 83% • 3 groups: standard care vs brief intervention vs brief intervention with booster (BIB) • All 3 groups reduced days of heavy drinking • Pts with history of hazardous drinking responded to BIB

15. COST-BENEFIT ANALYSIS OF BRIEF MOTIVATIONFleming MF, et al. Medical Care 2000; 38:7-18. • RCT (n=774 problem drinkers) • primary care practice, managed care setting • economic cost of intervention = $80,210 ($205 each) • economic benefit of intervention = $423,519 • $193,448 in ED and hospital use • $228,071 avoided costs in motor vehicle crashes and crime • 5.6 to 1 benefit to cost ratio • $6 savings for every $ invested

17. Project ASSERT: Boston Medical Center ED Follow-up at 60-90 Days (n=182) Mean AUDIT Scores: 68% Reduction in Alcohol Use

18. The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. • There was substantial evidence that MI is an effective substance abuse intervention method when used by clinicians who are non-specialists in substance abuse treatment, particularly when enhancing entry to and engagement in more intensive substance abuse treatment treatment-as-usual. Dunn C, Deroo L, Rivara FP. Addiction 2001; 96:1725-1742.

19. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials • Motivational interviewing (MI) was equivalent to other active treatments and yielded moderate effects (from .25 to .57) compared with no treatment and/or placebo for problems involving alcohol, drugs, and diet and exercise. • MI results: 51% improvement rate, a 56% reduction in client drinking, and moderate effect sizes on social impact measures (d=0.47). Burke BL, Arkowitz H, Menchola M. J Consult Clin Psychol 2003; 71:843-61.

20. JOIN TOGETHER FIGHTING BACK / DEMAND TREATMENT SITES • Project ASSERT at Sutter Solano - Vallejo CA • MOVE UP-Truman Medical Center, Kansas City MO • 813/1829 ED patients referred for SA rx • Project ASSERT - New Haven CN • 3600 screened; 85% of follow-up group got into tx • Pittsburgh, PA • Des Moines, IA • Denver, CO • San Diego, CA

21. What We Know about Brief Motivational Intervention BI appears to reduce alcohol-related harm • reduces alcohol use for at least 12 months • similar effect size for men and women • decreased GGT levels (Kristenson, 1983; Wallace, 1988; Israel, 1996) • decreased sick days (Kristenson, 1983) • decreased drinking and driving (Monti, 1999) • decreased scores on questionnaires regarding alcohol-related problems (Marlatt, 1998)

22. Nation’s Public Health Agenda:Healthy People 2010 26-22. Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these conditions in a hospital emergency department. DATA SOURCE: Ambulatory Medical Care Survey (NHAMCS)

23. So if brief intervention works and saves money…Why don’t ED providers screen, practice brief intervention, and refer, when indicated, to the substance abuse treatment system?