Transcript Yale University School of Medicine Screening, Brief Intervention and Referral to Treatment Gail D’Onofrio MD, MS Chief and Associate Professor Section of Emergency Medicine Yale University.

Yale University School of Medicine
Screening, Brief Intervention and
Referral to Treatment
Gail D’Onofrio MD, MS
Chief and Associate Professor
Section of Emergency Medicine
Yale University School of Medicine
Several Truths
• Treatment does work
• The ED/primary care visit is an opportunity for
intervention
• Timely referral is effective
• Practitioners are reluctant to screen and
intervene
• There are multiple barriers to SBI
Why is SBI Important?
• Alcohol problems are common
• Overall economic cost $185
billion/1998
• Risk factor injury and illness
• Problems occur throughout the life
cycle
Morbidity and Mortality
• >107,000 alcohol related deaths each year
• 1/3 of adult 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
Trauma Prevention
• Regional trauma centers (RTCs) were
developed 30 years ago
• Response to studies showing that 40% of
injuries in U.S. could have been prevented if
patient treated in facility with special expertise
• Today RTC’s reduced the preventable death rate
2-3%
• Conclusion: Any significant reduction in death
rates will depend on progress in injury
prevention
Gentilello, Annals of Surgery.1999:230:473
Top 10 Leading Causes of Death in the
United States for 2001, by Age Group
Alcohol-Related Fatalities
27,500
25,000
22,500
20,000
17,500
15,000
12,500
10,000
7,500
5,000
2,500
0
82
84
86
88
90
92
94
96
98
00
02
04
Source: FARS
BAC Levels for Alcohol Positive Drivers
Involved in Alcohol-Related Fatal Crashes
.16 = Median and Mode BAC
Number of Drivers
800
700
600
500
400
300
200
100
0
0
.05 .10 .15 .20 .25 .30 .35 .40 .45+
BAC -- 2002
Source: 2002 ARF FARS
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
Universal Screening Widens The Net
ABSTAINERS &
MILD DRINKERS
(70%)
MODERATE
(20%)
at risk drinkers
SEVERE
(10%)
Specialized Treatment
Brief Intervention
Primary Prevention
Social Morays
Stereotypic “Alcoholic”
Role of the Practitioner
•
•
•
•
Identify
Assess
Brief intervention
Refer
Screening
• Diagnostic tests
– Blood alcohol concentration (BAC)
– Saliva alcohol test
– Breathalyzer
– Adjunct tests (abnormal liver function tests,
macrocytic anemia)
Screening
• Structured questionnaires
– CAGE
– TWEAK
– AUDIT
– Brief MAST
– CRAFFT
• Quantity & frequency questions (NIAAA)
Sensitivity & Specificity of Screening
Instruments for Harmful & Dependent Drinkers
Screening
Instrument
Harmful
Dependent
S
SP
S
SP
CAGE
75
88
76
90
TWEAK
87
86
84
86
AUDIT
85
88
83
90
BMAST
31
98
30
99
Breath Alcohol
Analysis
20
94
20
94
Self Report
31
89
29
89
Cherpitel. Screening for Alcohol Problems in the Emergency Department.
Ann Emerg Med. 1995; 26: 163-164
ASK about Alcohol Use
Per week
• Consumption
Per occasion
• CAGE
ASK Current Drinkers
• On average, how many days per week do
you drink alcohol?
• On a typical day when you drink, how
many drinks do you have?
• What’s the maximum number of drinks you
had on a given occasion in the last month?
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
Screen Positive
Drinks per
week
> 14
Drinks per
occasion
Women
>7
>3
All Age >65
>7
>1
Men
>4
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
Drinking Patterns
% of
US adults
aged 18+
Abuse
without
dependence
Dependence
with or without
abuse
Exceeds daily limit
< once a week
16%
1 in 8
(12%)
1 in 20
(5%)
Exceeds daily limit
once a week or more
3%
1 in 5
(19%)
1 in 8
(12%)
Exceeds both
weekly & daily limits
9%
1 in 5
(19)
1 in 4
(28)
Source: NIAAA National Epidemiologic Survey on Alcohol and
Related Conditions, 2003
ASK Current Drinkers
CAGE
C
A
G
E
Cut Down
Annoyed
Guilty
Eye Opener
Assessment: Level of Severity
• At risk
No current problems
• Experiencing problems
Medical
Behavioral
• Signs of dependence
Assessment: Alcohol Dependence
ASK:
• Are there times when you’re unable to stop drinking?
• Does it take more drinks to get high?
• Do you feel a strong urge to drink?
• Do you change your plans to be able to drink?
• Do you drink early in the am to relieve the ‘shakes’?
THE SSOT*
Beecher's Immediate and Faithful
Self-examination of the Signs Of in Temperance
Ascertain whether any of the symptoms of intemperance are beginning to show
themselves upon you. And let not the consideration that you have never been
suspected, and have never suspected yourselves of intemperance, deprive you
of the benefit of this scrutiny.
1)
Are there then set times, days, and places, when you calculate always to
indulge yourselves in drinking ardent spirits?
2)
Do you stop often to take something at the tavern when you travel, and
always when you come to the village, town, or city?
*Beecher, L. (1828). Six sermons on the nature, occasions, signs, evils, and remedy of
intemperance. Boston, MA.
THE SSOT (cont.)
3)
Have you any friends or companions whose presence, when you meet
them, awakens the thought and the desire of drinking?
4)
Do any of you love to avail yourselves of every little catch and
circumstance among your companions, to bring out "a treat?"
5)
Do you find the desire of strong drink returning daily, and at stated hours?
6)
Do any of you drink in secret, because you are unwilling your friends or
the world should know how much you drink?
7)
Are you accustomed to drink, when opportunities present, as much as
you can bear without any public tokens of inebriation?
THE SSOT (cont.)
8) Do your eyes, in any instance, begin to trouble you by their
weaknesses or inflammation?
9) Do any of you find a tremour of the hand coming upon you,
and sinking of spirits, and loss of appetite in the morning?
10) Do the pains of a disordered stomach, and blistered tongue
and lip, begin to torment you?
Brief Intervention
• Short counseling sessions (5-45 minutes)
• Single or repeated sessions
• Performed by non-addiction specialists
• Contain advice and/or motivational
enhancement
Brief Intervention
• At risk/problem drinkers
– Advise to cut down
– Set goals
– Provide Primary Care follow-up
• Dependence
– Advise to abstain
– Refer to treatment
Stages of Change Model
Pre-Contemplation
Contemplation
Preparation
Maintenance
Action
Prochaska & DiClemente, 1986
A Disswasive from the Horrid and Beastly
Sin of Drunkenness [Anonymous, 1705]
•
•
•
“Drunkenness is a Sin which hath long been
called a Voluntary Madness”
“The means to keep from this beastly Sin,
next to the frequent Use of fervent prayer is,
carefully to avoid the Occasions and
Temptations that are apt to betray us to it.”
This Disswasive from Drunkenness is thus
printed in half a Sheet of Paper, that it may
be made up in the Form of a Letter, and
directed to any Persons that are guilty of it.
Babor TF. J of Consulting & Clinical Psychology 1194;62:1127-1140
Enhancing Motivation for Change:
FRAMES
F eedback (personalized, non-judgmental)
R esponsibility (respect for autonomy)
A dvice (clear and timely)
M enu of options (what works for you?)
E mpathy (reflective listening)
S elf-efficacy (offer optimism and hope)
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
Brief Intervention
• Bien et al. (Addiction 1993)
– 32 trials of BI in 14 nations
– BI is more effective than no counseling, and often as
effective as more extensive treatment
• Wilk et al. (J Gen Intern Med 1997)
– Pooled outcome data from 12 RCTs of BI
– odds ratio 1.9 (95% CI 1.61-2.27) in favor of BI
• D’Onofrio & Degutis (Acad Emerg Med)
– Review of 39 clinical trials: 30 (RCT) & 9 (Cohort)
– 32 studies reveal positive effect of BI
World Health Organization
(Am J Pub Health 1996)
“A cross-national trial of brief interventions with
heavy drinkers”
• Multinational study in 10 countries (n=1,260)
• Interventions included simple advice, brief & extended
counseling compared to control group
• Results: Consumption decreased
– 21% with 5 minutes advice, 27% with 15 minutes
compared to 7% controls
– Significant effect for all interventions
Fleming et al.
JAMA 1997;277:1039-1047
“Brief physician advice for problem alcohol
drinkers: a randomized control trial in
community-based primary care practices”
• BI in 17 practices with 64 physicians
• Intervention included: educational workbook,
(2) 15 minute visits one month apart, and
(2) nurse follow-up calls, 2 weeks after the visit
Fleming
• Results at 12 months (n=723)
Consumption:
(I)  19.1 drinks/wk to 11.5 vs (C) 18.9 to 15.2
Episodes of binge drinking during prior 30 days:
(I)  5.7 to 3.1 vs (C) 5.3 to 4.2
COST-BENEFIT ANALYSIS OF BRIEF MOTIVATION
Fleming MF, et al. Medical Care 2000; 38:7-18.
• RCT (n=774)
• primary care practice, managed care setting
• problem drinkers
• 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
Monti et al, J Consulting and Clinical
Psychology 1999
“Brief intervention for harm reduction with
alcohol-positive older adolescents in an ED”
• 94 patients (18-19 years) were randomized
• (I) group had a significant reduction in alcohol
use (p<.001) at 6 month f/u and were less likely
to report:
– 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)
Gentilello et al.
Annals Surgery1999;230:473-483
“Alcohol
Interventions in a Trauma Center
as a Means of Reducing Risk of Injury
Recurrence”
• Admitted injured patients who tested and/or
screened positive for alcohol problems were
randomized (n=732)
• Results at 12 months (54% follow-up rate):
(I)  alcohol consumption 21.8 drinks/week vs (C) 6.7
(p=0.03)
Gentilello
• Reduction most apparent in mild-moderate
drinkers:  21.6 drinks/week vs 2.3
drinks/week in controls (p<0.01)
• 47% reduction in new injuries requiring ED
visit or readmission to the trauma service
(p=0.07)
• 48% reduction in new injuries requiring
hospitalization at 3-year follow-up
Longabaugh R, et al.
J Stud Alcohol 2001;62:806-816
• n=539 injured ED patients with an AUDIT score of >8 or BAC > 0.03
mg/dl or reported ingestion 6 hours prior to injury
• 3 groups: standard care vs brief intervention (40-60 minutes) vs brief
intervention with booster 7-10 days after initial BI (BIB)
• 1 year f/u = 84%
• All 3 groups reduced days of heavy drinking
• BIB subjects had fewer DrInC consequences (2.24 vs 2.4 (BI) and
2.52 (SC))
• BIB had fewer alcohol-related injuries than SC (0.456 vs 0.165) The
average at baseline for whole sample 1.6
Components of the BNI
STEP 1:
Raise the Subject
STEP 2:
Provide Feedback
STEP 3:
Enhance Motivation
STEP 4:
Negotiate and Advise
Step 1: Raise the Subject
• Establish Rapport
• Raise the subject of alcohol use
“Hello, I am….... Would you mind taking a
few minutes to talk with me about your
alcohol use?”
Step 2: Provide Feedback
• Review patient’s drinking patterns
“From what I understand you are
drinking…”
• Make connection to ED visit if possible
“What connection (if any) do you see
between your drinking and this ED visit?”
Step 2: Provide Feedback (Cont.)
• Compare to National Norms and offer
NIAAA guidelines
“These are what we consider to be the
upper limits of low-risk drinking for your
age and sex. By low-risk we mean that
you would be less likely to experience
illness or injury.”
Step 3: Enhance Motivation
• Assess readiness to change
“On a scale of 1-10 (1 being not ready and
10 being very ready) how ready are you to
change any aspect your drinking?”
0
1
2
3
4
5
6
7
8
9
10
Step 3: Enhance Motivation (cont)
• Develop discrepancy
– Identify areas to discuss
– Explore pros and cons if low readiness #
– Use reflective listening
If patient indicates:
> 2 : “Why did you choose that number and not a lower
one? What are some reasons why you are thinking
about changing?”
< 1: “Have you ever done anything that you wish you
hadn’t while drinking? What would make this a
problem for you?”
Step 4: Negotiate and Advise
• Elicit response
“How does all this sound to you?”
• Negotiate a goal
“What would you like to do?”
• Give advice
“It is never safe to drink and drive, etc…”
• Summarize
“This is what I heard you say… Thank you…
(Provide PCP f/u or treatment referral)
Models for SBIRT in the ED
• Project ED Heath:
Emergency Practitioners
Harmful and Hazardous Drinkers
• Project ASSERT:
Health Promotion Advocates
Alcohol and Other Drug Misuse
and Dependence
Emergency Practitioner Brief Intervention for
Harmful and Hazardous Drinkers
PROJECT ED HEALTH
Gail D’Onofrio MD, Linda Degutis DrPH,
David Fiellin MD, Michael Pantalon PhD,
Susan Busch PhD, Marek Chawarski PhD,
Patrick O’Connor MD
(NIAAA 1 R01 AA12417)
Project ED Health
• Funded by NIAAA
RO1 AA12417-01A1
• Collaborative initiative
Emergency Medicine
Medicine
Psychiatry
Project ED Health: Primary Aims
• To develop, implement and test an EPperformed brief intervention for harmful
and hazardous drinkers
• To determine the efficacy of these brief
interventions on reducing alcohol
consumption and negative consequences
Hazardous/harmful drinking
• Hazardous drinking
– Exceed NIAAA guidelines
• Male, > 14 drinks per week, > 4 drinks per occasion
• Female, > 7 drinks per week, > 3 drinks per occasion
• >65, > 7 drinks per week, > 3 drinks per occasion
• Harmful drinking
– Injury with blood alcohol concentration > 0.2gm/dl
Patients
• ED patients were screened using the NIAAA
quantity/frequency questions embedded in an
18-item health quiz
– Inclusion
• >18 years old
• Harmful/hazardous drinking
– Exclusion
•
•
•
•
alcohol dependence (AUDIT scores >19)
cognitive impairment
critical illness
drug dependence
Study Design
• Prospective Observational Study
– EP (EM faculty, residents and physician
associate) education
• Randomized clinical trial
– Brief Negotiation Interview (BNI) vs.
Discharge Instructions
Training
• Emergency Practitioners (EPs)
– MD faculty, 3rd and 4th year residents and Physician
Associates were trained to perform BNI
• 2-hour teaching sessions conducted by PI and
Co-investigators consisted of:
–
–
–
–
30 min didactic presentation
10 min role play demonstration
50 min case-based workshop
30 min debriefing and (Q &A)
Results: EP Training and Proficiency
Passed
53 (91%)
BNI Trained
58 EPS
Not trained
2 EPs
1-fellow
1-sabbatical
Remediated
& Passed
3 (5%)
3-PAs
No
Remediation
2 (4%)
Left institution
1-faculty
1-resident
BNI Performance
• 47 of 58 EPs performed BNIs
– Mean # BNIs performed per EP
• 5.28 ( + 4.91; range 0-28)
– Mean duration of BNI
• 7.75 minutes ( + 3.18; range 4-24)
• 241 exit interviews with EPs
– 237/241, EPs reported no problems with BNI
– 4/241, EPs reported BNI interrupted due to
consultations or diagnostic testing
Conclusions: Project ED Health
• A BNI for Harmful and Hazardous drinkers
can be successfully developed for
Emergency Practitioners.
• Emergency Practitioners can demonstrate
proficiency in performing the BNI in routine
ED clinical practice
Project ED Health
Results of RCT
Counseling Interventions
• Brief Negotiation Interview (BNI)
– Provided by Emergency Practitioners (MD, PA)
– Less than 10 minutes
– Manual-guided script
•
•
•
•
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
• Discharge Instructions (DI)
– Advice to decrease drinking embedded in a sheet providing
advice on general health (e.g. smoking cessation, exercise, seatbelt use)
Counseling Competency
• All EPs evaluated using standardized patient
– audio-taped to ensure adherence to and competence
with BNI
– Rater evaluated whether critical actions were
completed
• Failure resulted in additional instruction and
retesting
Data Collection
• Research assessments completed at baseline in
the ED and at 1, 6 and 12 months by phone
• Alcohol consumption
– Time-line follow back
• Negative consequences
– Self-report of:
•
•
•
•
Injury
Motor Vehicle Crashes
Driving while intoxicated
Missed work
Adherence and Fidelity
• BNIs and DIs audio-taped ~ (90%)
• Rated for adherence to protocol
Results
14,771
Screened
571
Eligible
500
Randomized
250
BNI
71
Not Randomized
67 refused
4 missed
250
DI
Demographics
• Male: 68%
• Mean age 35.3; SD+15.9
• Race: 385 (77%) White, 104 (21%) Black
• ED visit prompted by injury: 34%
• ~30% had AUDIT scores < 8
• No difference by sex, age, race, or injury presentation
Drinks per week
BNI
DI
P
Baseline
13.5
12.6
NS
1 month
8.5
9.6
NS
6 months
9.5
9.3
NS
12 months
9.9
10.0
NS
Binge drinking
(% binging in past 30 days)
BNI
DI
P
Baseline
92%
89%
NS
1 month
55%
53%
NS
6 months
54%
54%
NS
12 months
52%
51%
NS
Drinks per week
(by AUDIT score and condition)
30
Average number of drinks per week
25
20
15
10
5
0
Baseline
AUDIT <8 BNI
1 month
AUDIT <8 DI
AUDIT 8-15 BNI
6 months
AUDIT 8-15 DI
12 months
AUDIT >15 BNI
AUDIT >15 DI
Drinks per week
(by gender and condition)
18
Average number of drinks per week
16
14
12
10
8
6
4
2
0
Baseline
1 month
Males BNI
6 months
Males DI
Females BNI
12 months
Females DI
Negative consequences
(Injuries while drinking)
BNI
DI
P
Baseline
18
12
NS
12 months
8
10
<.03
Negative consequences
(Women, drinking while driving)
BNI
DI
P
Baseline
24
2
NS
12 months
15
19
<.05
Adherence & Competence
• A Brief Intervention Adherence/Competence Scale
• Independent tape rater training
• Use of the scale to:
– discriminate between BNI & DI
– assess the degree to which each Rx was
administered as intended
– evaluate the association between
adherence/competence and drinking outcomes
(on-going)
BI Adherence/Competence Scale
Did the ED Provider (EP)…(YES, NO)
1) Ask patient for permission to discuss alcohol use & pause
for answer?
2) Review patient’s drinking patterns and express concern?
3) Ask patient if he/she sees a connection between drinking &
ED visit?
4) Make a specific connection between drinking and ED visit
or other medical issue (e.g., MVC, GI complaints,
hypertension)?
BI Adherence/Competence Scale
5) Inform pt re: NIAAA guidelines relevant to his/her sex
and age group and tell patient his/her drinking is above
guidelines and unsafe?
6) Ask patient to select a number on the “Readiness
Ruler”?
7) What was the number?
8) Ask patient why he/she did not pick a lower number?
BI Adherence/Competence Scale
9) Ask Patient: What would make his/her drinking a
problem? OR Ask how important would it be for the
patient to prevent that from happening? OR Discuss
patient’s pros and cons of drinking?
10) Tell patient in a confrontational manner, that they have
to cut down?
11) Make suggestions regarding how much patient
should cut down?
12) Refer to patient as an “alcoholic”
BI Adherence/Competence Scale
13) Negotiate a drinking goal with the patient based on what
patient has said by asking: What would you like to do?
14) Tell patient that if he/she can stay within NIAAA limits
he/she will be less likely to experience (further) illness
or injury related to alcohol use?
15) Provide a drinking agreement sheet?
16) Add his/her advice on the agreement?
17) Provide “Project ED Health” Information sheet?
BI Adherence/Competence Scale
18) Encourage patient to follow-up with his/her PCP?
19) Thank patient for his/her time?
20) Offer confrontational warnings regarding drinking?
21) To what degree does the provider reflect patient’s
motivational statements regarding cutting down? (1-7)
22) Re-direct non-motivational statements? (1-7)
Independent Tape Rater Training
• 4 Raters trained
– 4 hours of didactics & tape rating practice PLUS a 1hour booster
– 5 training tapes rated by each rater (>85% agreement)
• Inter-rater reliability
– 20 tapes given to remaining 3 raters
– 15 tapes were rated
– Mean agreement across all items=82%
– >80% agreement on all items except for:
•
•
•
•
Made suggestions re: how much to cut down (33.3% agreement)
Negotiated drinking goal (73.3% agreement)
Informed pt that staying within limits lowers risk (33.3 agreement )
Added advice to drinking agreement (53.3% agreement)
Discriminating between BNI & DI
sessions (N=367)
• Session Length
– Mean BNI min. > Mean DI min. (6.73 vs. 1.38, p<.01)
• Adherence/Competence
Score
Treatment Group
BNI*
DI
BNI
8.9
0.69
DI
0.5
0.88
*BNI scores range is from -3 to 13, which excludes DI-prescribed items;
BNI sessions’ BNI score > DI, p<.01
• Item analyses revealed significantly greater use of BNI
components in BNI vs. DI group on all items (p<.01), except
for info sheet item (DI>BNI) and proscribed items, where
frequency low & comparable between the 2 groups.
• BNI > DI on Reflective listening scores, but very little was
actually done (2.20/7 vs. 1/7, p<.01).
To what degree did EPs administer BNI
as intended?
• BNI Passing Score of 12/15 (80%) achieved in
42% of BNI sessions (X=10.3/15 or 69%)
• Contrary to the manual, however, 8% of BNI
sessions included some “confrontational
warnings regarding drinking”
• Additionally, the BNI components most
frequently & mistakenly omitted were…
– Inform pts of benefits of staying within limits (47.3%)
– Providing pts with info sheet (30.8%)
To what degree did EPs administer
DI as intended?
• DI Passing Score of 1 (i.e., info sheet provided without
any use of BNI components) achieved in 64.3% of DI
sessions
• However, 33% of DI sessions included at >1 BNI
components…
– 21.2% “asked permission to talk about alcohol”
– 6% “made a specific connection between drinking &
ED visit…” and/or used word “alcoholic”
– 3% “reviewed drinking patterns & expressed
concern...” or “offered confrontational warnings”
• Additionally, the 1 critical DI component (i.e., giving info
sheet) was mistakenly omitted in 6% of DI sessions.
Adherence & Competence
Conclusions
• BNI & DI are discriminable
• Both treatments were administered with fair-to-good
adherence and competence during the trial
• However, some prescribed components were missed
(benefits of change and directive advice-giving in the BNI
group & info sheet in DI) and some proscribed
components were included in both treatments
(confrontation, use of “alcoholic”).
• This may have lessened the overall contrast between
the 2 treatment conditions and may have contributed to
the “no difference” finding.
• These findings and on-going analyses on the association
between the various BNI components and drinking
outcomes will shape our understanding of the BI
techniques most critical to promoting change in
harmful and hazardous drinkers in the ED.
Summary
• BNI and DI are associated with decreased
alcohol consumption in harmful/hazardous
drinking in the ED
• BNI is associated with decreased negative
consequences including injury, and
drinking and driving in females
Conclusion
• BNI is teachable and acceptable to EPs
• BNI is feasible to perform in ED setting in
the context of routine clinical care
• Unable to demonstrate significant
difference between BNI and DI with
respect to alcohol consumption
• Strategies to augment BNI need to be
evaluated
Project ASSERT
• Funded by:
– Robert Wood Johnson Foundation,
New Haven Fighting Back Initiative
– CT Department of Mental Health and
Addiction Services
– Section of Emergency Medicine, Yale
University School of Medicine
Health Promotion Advocates (HPAs)
Project ASSERT
• Background
– Community outreach workers who identify and
provide early intervention for ED patients with alcohol
and other drug problems & other selected health risks
such as domestic violence, smoking, depression, and
access to primary care
• Model
–
–
–
–
–
Implementation:
Participants:
Survey:
Intervention:
Follow-up:
HPAs 2.6 FTE
> 18 years-old
10 min face-to-face interview
Brief Intervention, referrals
Phone \ facility contact
Screening
• In 5 years the Project ASSERT team has
successfully screened over 18,000 patients
Other
3%
Hispanic
25%
White
44%
Black
28%
Alcohol Consumption
n
%
Alcohol Consumption
10,075
42.3 (23,727)
Exceeds NIAAA
Criteria
At Risk/Hazardous
9,720
96.3
5,776
57.2
3,944
39.1
1,551
15.4
(Exceeds NIAAA, CAGE <1)
Dependence
(Exceeds NIAAA, CAGE >2)
Binge Drinking
Other Drug Use
• 15% of all patients use illicit drugs
• Most common drugs used are:
– cocaine/crack(59%)
– heroin (38%)
– marijuana(36%)
Referrals to Specialized Treatment Centers
Referrals
3,249
Other Drugs
23%
Alcohol and
Other Drugs
12%
Alcohol
65%
Treatment Enrollment
Enrolled
Enrolled
87.5%
89%
Not
Not
Enrolled
11%
Enrolled
12.5%
Percentages were calculated from patients that were contacted 2,416
(74.4% of total referred), divided by patients who enrolled 2113 (87.5%).
Conclusions: Project ASSERT
• The Project ASSERT model can
– be successfully integrated into the real world
ED setting
– directly link patients to specialized treatment
programs
Summary
• SBI is a skill that can be learned by Emergency
Practitioners and peer educators
• Health Promotion Advocates can successfully
link ED patients with specialized treatment
programs
• System to drive SBI must be developed
Strategies to Drive Change
• Overcome Clinical Inertia
– Recognition of the problem, but failure to act.
(Phillips LS Ann Intern Med 2001;135:825-34)
•
•
•
•
•
Provide skills-based workshops
Elicit opinion leaders
Institute system changes
Provide ongoing feedback & incentives
Be creative
The Diffusion of Innovations to Prevent Disease,
Disability and Death: An Historical Perspective
•
•
•
•
Brief interventions:
SSOT screening:
Scurvy:
SBIR:
300 yrs
175+ years
50 years
25 years
Thomas F. Babor