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Brief Intervention and Brief Intervention and Referral to Treatment Referral to Treatment EMERGENCY MEDICINE
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Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Jan 16, 2016

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Page 1: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Brief Intervention and Brief Intervention and Referral to TreatmentReferral to Treatment

EMERGENCY MEDICINE

Page 2: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Morbidity and MortalityMorbidity and Mortality

>107,000 alcohol related deaths each year>107,000 alcohol related deaths each year 1/3 of adult hospital admissions are alcohol related1/3 of adult hospital admissions are alcohol related Attributable risk factor for multiple illnessesAttributable risk factor for multiple illnesses Major risk factor for all categories of injuryMajor risk factor for all categories of injury

Problem drinkers have 2x injury events/yr and 4x as Problem drinkers have 2x injury events/yr and 4x as many hospitalizations for injurymany hospitalizations for injury

A single alcohol-related visit predicts continued A single alcohol-related visit predicts continued problem drinkingproblem drinking

Social and family issuesSocial and family issues

Page 3: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol Related Injuries Alcohol Related Injuries

150,000 injury deaths in U.S. each 150,000 injury deaths in U.S. each yearyear

several hundred thousand disabling several hundred thousand disabling injuries per yearinjuries per year

15-34 years olds at highest risk15-34 years olds at highest risk alcohol use involved in large alcohol use involved in large

proportion of deaths and injuriesproportion of deaths and injuries

Page 4: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol Related Alcohol Related CostsCosts

Medical treatment, insurance, Medical treatment, insurance, unemployment, lack of productivityunemployment, lack of productivity

Families with an alcoholic member Families with an alcoholic member have twice the average monthly have twice the average monthly health care bill than other familieshealth care bill than other families

Page 5: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol Related CasualtiesAlcohol Related Casualties

Under reported on death certificatesUnder reported on death certificates Under reported on hospital dischargeUnder reported on hospital discharge Selection and recording biasSelection and recording bias

Page 6: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.
Page 7: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.
Page 8: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol-Related Fatalities in Alcohol-Related Fatalities in MVCsMVCs

0

2,500

5,000

7,500

10,000

12,500

15,000

17,500

20,000

22,500

25,000

27,500

82 84 86 88 90 92 94 96 98 00 02 04

Source: FARS

Page 9: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

BAC Levels for Alcohol Positive Drivers BAC Levels for Alcohol Positive Drivers Involved in Alcohol-Related Fatal CrashesInvolved in Alcohol-Related Fatal Crashes

Source: 2002 ARF FARS

.16 = Median and Mode BAC

Page 10: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Drinking Patterns in the U. S.

Dependent 5%

At Risk or Problem20%

Source: National Longitudinal Alcohol Epidemiologic Survey, 1992

Low Risk 35%

Abstain 40%

Page 11: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Prevention and Intervention

ABSTAINERS & MILD DRINKERS

(70%)

MODERATE(20%)

at risk drinkers

SEVERE (10%)

Primary Prevention

Brief Intervention

Specialized Treatment

Page 12: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol TerminologyAlcohol Terminology

Hazardous drinking - at-risk drinkingHazardous drinking - at-risk drinking NIAAA definitionNIAAA definition

Harmful drinkingHarmful drinking Health consequencesHealth consequences

Binge drinkingBinge drinking 5 or more drinks per drinking episode5 or more drinks per drinking episode

Page 13: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol TerminologyAlcohol Terminology Dependence - cluster of symptoms Dependence - cluster of symptoms

including impaired control over intake, including impaired control over intake, withdrawal symptoms, tolerance, drinking withdrawal symptoms, tolerance, drinking despite problemsdespite problems

Abuse - repetitive patterns of drinking in Abuse - repetitive patterns of drinking in harmful situations with adverse harmful situations with adverse consequences, including impaired ability to consequences, including impaired ability to fulfill responsibilities or negative effects on fulfill responsibilities or negative effects on social/interpersonal functioning and healthsocial/interpersonal functioning and health

Page 14: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Issues related to lack of Issues related to lack of exploration of alcohol useexploration of alcohol use

Lack of understanding of problemLack of understanding of problem Failure to acknowledge responsibility for Failure to acknowledge responsibility for

identification/interventionidentification/intervention Biases - personal/professionalBiases - personal/professional Feeling that nothing can be doneFeeling that nothing can be done Not knowing what can be doneNot knowing what can be done Outside of what is thought to be the Outside of what is thought to be the

traditional realm of medical care providerstraditional realm of medical care providers

Page 15: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Issues Related to ED Issues Related to ED Provider Screening for Provider Screening for

Alcohol UseAlcohol Use Alcohol screening not Alcohol screening not

traditionally part of physician jobtraditionally part of physician job Not comfortable with alcohol Not comfortable with alcohol

related issuesrelated issues Don’t know how to interveneDon’t know how to intervene Frustration over prior experiences Frustration over prior experiences

with patients who abuse alcoholwith patients who abuse alcohol

Page 16: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol Use as Part of the Alcohol Use as Part of the Medical HistoryMedical History

Alcohol useAlcohol use QuantityQuantity FrequencyFrequency Type of alcohol usedType of alcohol used Problems related to alcohol useProblems related to alcohol use

Page 17: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol Screening - IssuesAlcohol Screening - Issues

Not seen as responsibility of physician Not seen as responsibility of physician in EDin ED

Included as part of “social” historyIncluded as part of “social” history Providers not educated concerning Providers not educated concerning

importance of alcohol screening as importance of alcohol screening as routine practiceroutine practice

Providers not educated concerning Providers not educated concerning how to ask the questionshow to ask the questions

Page 18: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Alcohol InterventionsAlcohol Interventions

Brief interventionBrief intervention Further evaluation and more Further evaluation and more

extensive intervention for extensive intervention for person with more significant person with more significant problemproblem

Provider intervention may be Provider intervention may be more effectivemore effective

Page 19: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Social Morays Social Morays

Page 20: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

A Standard DrinkA Standard DrinkA standard drink is 12 grams of pure alcohol A standard drink is 12 grams of pure alcohol

or:or:

• One 12-ounce bottle of beer or wine One 12-ounce bottle of beer or wine coolercooler

• One 5-ounce glass of wineOne 5-ounce glass of wine• 1.5 ounces of distilled spirits1.5 ounces of distilled spirits

Page 21: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Screen PositiveScreen Positive

Drinks perDrinks per

weekweekDrinks per Drinks per occasionoccasion

MenMen > 14> 14 > 4> 4

WomenWomen > 7> 7 > 3> 3

All Age >65All Age >65 > 7> 7 > 1> 1

Page 22: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Drinking Patterns: Rates and Risks Drinking Patterns: Rates and Risks Binge DrinkingBinge Drinking

The National Advisory Council on Alcohol Abuse and The National Advisory Council on Alcohol Abuse and Alcoholism has recommended the following definition of Alcoholism has recommended the following definition of “Binge Drinking”: “Binge Drinking”:

A “binge” is a pattern of drinking alcohol that brings A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gm% or blood alcohol concentration (BAC) to 0.08 gm% or above. For the typical adult, this pattern corresponds to above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male) or 4 or more drinks consuming 5 or more drinks (male) or 4 or more drinks (female) in about 2 hours. (female) in about 2 hours.

Binge drinking is clearly dangerous for the drinker and Binge drinking is clearly dangerous for the drinker and for society for society

Page 23: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Brief InterventionBrief Intervention

Short counseling sessions (5-45 Short counseling sessions (5-45

minutes)minutes) Single or repeated sessionsSingle or repeated sessions Performed by non-addiction specialistsPerformed by non-addiction specialists Contain advice and/or motivational Contain advice and/or motivational

enhancement enhancement

Page 24: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Brief InterventionBrief Intervention

At risk/problem drinkersAt risk/problem drinkers Advise to cut downAdvise to cut down Set goalsSet goals Provide Primary Care follow-upProvide Primary Care follow-up

DependenceDependence Advise to abstainAdvise to abstain Refer to treatmentRefer to treatment

Page 25: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

ABSTAINABSTAIN pregnant or pregnant or

consideringconsidering medication that medication that

interactsinteracts dependencedependence failed attempts to failed attempts to

cut downcut down contraindicated contraindicated

medical conditionmedical condition

CUT DOWNCUT DOWN drinking above low drinking above low

risk amountsrisk amounts no dependenceno dependence no problemsno problems

Advise: What?

Page 26: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

Stages of Change Model

Pre-Contemplation Contemplation

Maintenance

Action

Preparation

Prochaska & DiClemente, 1986

Page 27: Brief Intervention and Referral to Treatment EMERGENCY MEDICINE.

General Principles for General Principles for Negotiating Behavior ChangeNegotiating Behavior Change

Respect for autonomy of patients and their Respect for autonomy of patients and their choices choices

Readiness to change must be taken into Readiness to change must be taken into accountaccount

Ambivalence is common Ambivalence is common Targets selected by the patient, not the expertTargets selected by the patient, not the expert Expert is the provider of the information Expert is the provider of the information Patient is the active decision-makerPatient is the active decision-maker

Rollnick, 1994Rollnick, 1994