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

The Rationale for The Rationale for

Screening, Brief Intervention Screening, Brief Intervention

and Referral and Referral

in the Medical Setting in the Medical Setting

WHY EARLY INTERVENTION FOR WHY EARLY INTERVENTION FOR HIGH-RISK AND DEPENDENT DRINKING?HIGH-RISK AND DEPENDENT DRINKING?

• High-risk and dependent drinking reduces quality and High-risk and dependent drinking reduces quality and

length of life, and is costly to individuals and society.length of life, and is costly to individuals and society.

• The medical encounter is too important a prevention The medical encounter is too important a prevention

opportunity to miss. opportunity to miss.

• Physician feedback & advice is a powerful motivator. Physician feedback & advice is a powerful motivator.

• Intervention results in improved prognosis. Intervention results in improved prognosis.

• Intervention reduces ED utilization & cost.Intervention reduces ED utilization & cost.

Alcohol & Other Drug Dependence, A Chronic IllnessAlcohol & Other Drug Dependence, A Chronic Illness

• <30% of patients with adult onset asthma, HTN, diabetes <30% of patients with adult onset asthma, HTN, diabetes

adhere to prescribed diet and/or behavioral changes adhere to prescribed diet and/or behavioral changes

• 50% of adults with these chronic conditions experience 50% of adults with these chronic conditions experience

recurrence of sx yearly, requiring additional medical carerecurrence of sx yearly, requiring additional medical care

• 50-60% of patients discharged from substance abuse 50-60% of patients discharged from substance abuse

treatment are abstinent at 1 yeartreatment are abstinent at 1 year

• As in other chronic diseases, poor adherence and relapse As in other chronic diseases, poor adherence and relapse

is predicted by low SES, co-morbid psych conditions and is predicted by low SES, co-morbid psych conditions and

lack of family and social supportslack of family and social supports

• Substance abuse should be insured, monitored, treated Substance abuse should be insured, monitored, treated

and evaluated like other chronic diseasesand evaluated like other chronic diseases

McClellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.McClellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.

Health Care Settings UsingHealth Care Settings UsingBrief Motivational InterventionBrief Motivational Intervention

• Trauma CentersTrauma Centers

• Emergency DepartmentsEmergency Departments

• General Medical PracticeGeneral Medical Practice

• Family Medicine & Primary CareFamily Medicine & Primary Care

• Pediatrics & Adolescent MedicinePediatrics & Adolescent Medicine

• Inpatient Consult ServiceInpatient Consult Service

• Oral and Maxillofacial SurgeryOral and Maxillofacial Surgery

• Psychiatric Services Psychiatric Services

• Student Health CentersStudent Health Centers

• Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation

Public Health ParadigmPublic Health Paradigm

The primary goal of brief intervention is toThe primary goal of brief intervention is to

– reduce alcohol use to low-risk levels reduce alcohol use to low-risk levels

– encourage abstinence in persons who encourage abstinence in persons who

are alcohol-dependent are alcohol-dependent

BRIEF INTERVENTION: A REVIEWBRIEF INTERVENTION: A REVIEW

• Chafetz et al, 1961Chafetz et al, 1961

– Randomized, controlled trial (n=200)Randomized, controlled trial (n=200)

– 65% of those receiving brief intervention in the 65% of those receiving brief intervention in the

MGH ED kept a subsequent appointment for MGH ED kept a subsequent appointment for

specialized treatment compared to 5% of specialized treatment compared to 5% of

controls. controls.

– 40% kept 5 appointments.40% kept 5 appointments.

(Establishing treatment relations with alcoholics. J Nerv Ment Dis 1962; 134: 390-410.)

ALCOHOL TREATMENT WORKSALCOHOL TREATMENT WORKS

• McClellan (1982)McClellan (1982) showed treatment effects at showed treatment effects at 6 months f/u on ASI measures of alcohol use, 6 months f/u on ASI measures of alcohol use, drug use, family interactions, work, legal and drug use, family interactions, work, legal and psychological functionpsychological function– 54% reduction in drinking days54% reduction in drinking days– 67% reduction in days intoxicated67% reduction in days intoxicated– 41% of participants abstinent for 30 days 41% of participants abstinent for 30 days

prior to follow-upprior to follow-up– 151% increase in income151% increase in income

McClellan TA, Luborsky L, O’Brien CP, et al. Is treatment for substance abuse effective? JAMA 1982; 247:1423-1428.

BRIEF INTERVENTION: A REVIEWBRIEF INTERVENTION: A REVIEW

• Bien TH, Miller WR, Tonigan JS, 1993Bien TH, Miller WR, Tonigan JS, 1993

– meta-analysis (n=6000)meta-analysis (n=6000)

13 randomized trials; 32 controlled trials13 randomized trials; 32 controlled trials

– more effective than no counselingmore effective than no counseling

– as effective as traditional therapy in 11/13 trialsas effective as traditional therapy in 11/13 trials

Brief intervention for alcohol problems: A review. Brief intervention for alcohol problems: A review.

AddictionAddiction 1993; 88: 315-335. 1993; 88: 315-335.

Alcohol Intervention in a Trauma Center Alcohol Intervention in a Trauma Center to Reduce Injury Recurrenceto Reduce Injury Recurrence

• Randomized, controlled trialRandomized, controlled trial

• Level 1 Trauma Center patients screened with blood Level 1 Trauma Center patients screened with blood alcohol , GGT, and Michigan Alcoholism Screening alcohol , GGT, and Michigan Alcoholism Screening Test (SMAST) Test (SMAST)

• 772 positives randomized to intervention or control 772 positives randomized to intervention or control

• Re-injury detected by computer search of statewide Re-injury detected by computer search of statewide ED and hospital discharge recordsED and hospital discharge records

• Alcohol use assessed at 6 and 12 monthsAlcohol use assessed at 6 and 12 months

Gentilello, Rivara et al. Gentilello, Rivara et al. Ann SurgAnn Surg 1999; 230: 473-483 1999; 230: 473-483

Trauma Center ResultsTrauma Center Results

• 1153 (46%) of 2524 screened positive1153 (46%) of 2524 screened positive

• intervention n = 366 vs control n = 396intervention n = 366 vs control n = 396

• at 6 months, decreases in at 6 months, decreases in bothboth groups (NS) groups (NS)

• at 12 months, reduced alcohol consumption at 12 months, reduced alcohol consumption

– down by 22 drinks per week in intervention groupdown by 22 drinks per week in intervention group

– down 6.7 drinks per week in control groupdown 6.7 drinks per week in control group

• reduced number of injuries requiring ED or admission reduced number of injuries requiring ED or admission

– down 47% in the intervention group vs controls down 47% in the intervention group vs controls

Gentilello, Rivara et al. Gentilello, Rivara et al. Ann SurgAnn Surg 1999; 230: 473-483 1999; 230: 473-483

D’Onofrio & Degutis D’Onofrio & Degutis (Acad Emerg Med)(Acad Emerg Med)

• Review of 39 clinical trials Review of 39 clinical trials

– 30 (RCT) 30 (RCT)

– 9 (Cohort)9 (Cohort)

• 32 studies reveal positive effect of BI32 studies reveal positive effect of BI

Brief Intervention for Harm Reduction With Brief Intervention for Harm Reduction With Alcohol + Older Adolescents in a Hospital EDAlcohol + Older Adolescents in a Hospital ED

• Population:Population: 18 to 19 year olds (n = 94) 18 to 19 year olds (n = 94)

• Site:Site: Rhode Island Hospital PED Rhode Island Hospital PED

• Intervention:Intervention: motivational intervention by masters motivational intervention by masters

level practitioners, primarily social workers level practitioners, primarily social workers

• Outcomes:Outcomes: alcohol consumption, drinking and alcohol consumption, drinking and

driving, alcohol related problems, injuries, moving driving, alcohol related problems, injuries, moving

violations (DMV)violations (DMV)

• Design:Design: RCT with 3 and 6 month f/u RCT with 3 and 6 month f/u

Monti P, et al. Monti P, et al. J Consult Clin J Consult Clin PsycholPsychol 1999; 67:989-994. 1999; 67:989-994.

Monti et al. Results of Brief Motivation Monti et al. Results of Brief Motivation with Adolescent ED Patientswith Adolescent ED Patients

• Follow-up rate: 93% at 3 months, 89% at 6 monthsFollow-up rate: 93% at 3 months, 89% at 6 months

• Moving violations: 3% in the intervention group vs 26% in the Moving violations: 3% in the intervention group vs 26% in the

control groupcontrol group

• Similar reductions in alcohol use despite differences in Similar reductions in alcohol use despite differences in

alcohol related consequencesalcohol related consequences

– having driven after drinking ( p<0.05)having driven after drinking ( p<0.05)

– having had alcohol involved in an injury (p<0.01)having had alcohol involved in an injury (p<0.01)

– to have had alcohol-related problems (p<0.05)to have had alcohol-related problems (p<0.05)

Evaluating the effects of a brief motivational Evaluating the effects of a brief motivational intervention for injured drinkers in the ED. intervention for injured drinkers in the ED.

Longabaugh R, Woolard RE, Nirenberg TD, et al. Longabaugh R, Woolard RE, Nirenberg TD, et al. J Stud AlcoholJ Stud Alcohol 2001 2001

• n=539 injured ED patients with an AUDIT score of n=539 injured ED patients with an AUDIT score of

>>8 or alcohol in system at the time of injury8 or alcohol in system at the time of injury

• 1 year f/u = 83%1 year f/u = 83%

• 3 groups: standard care vs brief intervention vs 3 groups: standard care vs brief intervention vs

brief intervention with booster (BIB)brief intervention with booster (BIB)

• All 3 groups reduced days of heavy drinkingAll 3 groups reduced days of heavy drinking

• Pts with history of hazardous drinking responded Pts with history of hazardous drinking responded

to BIBto BIB

COST-BENEFIT ANALYSIS OF BRIEF MOTIVATIONCOST-BENEFIT ANALYSIS OF BRIEF MOTIVATIONFleming MF, et al. Fleming MF, et al. Medical CareMedical Care 2000; 38:7-18. 2000; 38:7-18.

• RCT (n=774 problem drinkers)RCT (n=774 problem drinkers)

• primary care practice, managed care settingprimary care practice, managed care setting

• economic cost of intervention = $80,210 ($205 each)economic cost of intervention = $80,210 ($205 each)

• economic benefit of intervention = $423,519economic benefit of intervention = $423,519

– $193,448 in ED and hospital use$193,448 in ED and hospital use

– $228,071 avoided costs in motor vehicle crashes $228,071 avoided costs in motor vehicle crashes

and crimeand crime

– 5.6 to 1 benefit to cost ratio5.6 to 1 benefit to cost ratio

– $6 savings for every $ invested$6 savings for every $ invested

Project ASSERT: Boston Medical Center ED Project ASSERT: Boston Medical Center ED Follow-up at 60-90 Days (n=182)Follow-up at 60-90 Days (n=182)

Mean AUDIT Scores: 68% Reduction in Alcohol Use Mean AUDIT Scores: 68% Reduction in Alcohol Use

3.5

1.5

3

0.9

0

0.5

1

1.5

2

2.5

3

3.5

Drinking Frequence Binge Drinking Frequency

at enrollment at follow-up

The use of brief interventions adapted The use of brief interventions adapted from motivational interviewing across from motivational interviewing across

behavioral domains: a systematic review.behavioral domains: a systematic review.

• There was substantial evidence that MI is an There was substantial evidence that MI is an

effective substance abuse intervention method effective substance abuse intervention method

when used by clinicians who are non-specialists when used by clinicians who are non-specialists

in substance abuse treatment, particularly when in substance abuse treatment, particularly when

enhancing entry to and engagement in more enhancing entry to and engagement in more

intensive substance abuse treatment treatment-intensive substance abuse treatment treatment-

as-usual. as-usual.

Dunn C, Deroo L, Rivara FP. Dunn C, Deroo L, Rivara FP. AddictionAddiction 2001; 96:1725-1742. 2001; 96:1725-1742.

The efficacy of motivational interviewing: The efficacy of motivational interviewing: A meta-analysis of controlled clinical trialsA meta-analysis of controlled clinical trials

• Motivational interviewing (MI) was equivalent to other Motivational interviewing (MI) was equivalent to other active treatments and yielded moderate effects active treatments and yielded moderate effects (from .25 to .57) compared with no treatment and/or (from .25 to .57) compared with no treatment and/or placebo for problems involving alcohol, drugs, and placebo for problems involving alcohol, drugs, and diet and exercise. diet and exercise.

• MI results: 51% improvement rate, a 56% reduction MI results: 51% improvement rate, a 56% reduction in client drinking, and moderate effect sizes on social in client drinking, and moderate effect sizes on social impact measures (d=0.47). impact measures (d=0.47).

Burke BL, Arkowitz H, Menchola M. Burke BL, Arkowitz H, Menchola M. J Consult Clin PsycholJ Consult Clin Psychol 2003; 71:843-61. 2003; 71:843-61.

JOIN TOGETHERJOIN TOGETHER FIGHTING BACK / DEMAND TREATMENT SITES FIGHTING BACK / DEMAND TREATMENT SITES

• Project ASSERT at Sutter Solano - Vallejo CAProject ASSERT at Sutter Solano - Vallejo CA

• MOVE UP-Truman Medical Center, Kansas City MOMOVE UP-Truman Medical Center, Kansas City MO

– 813/1829 ED patients referred for SA rx 813/1829 ED patients referred for SA rx

• Project ASSERT - New Haven CN Project ASSERT - New Haven CN

– 3600 screened; 85% of follow-up group got into tx3600 screened; 85% of follow-up group got into tx

• Pittsburgh, PAPittsburgh, PA

• Des Moines, IADes Moines, IA

• Denver, CODenver, CO

• San Diego, CASan Diego, CA

BI appears to reduce alcohol-related harmBI appears to reduce alcohol-related harm

reduces alcohol use for at least 12 monthsreduces alcohol use for at least 12 months

similar effect size for men and womensimilar effect size for men and women

decreased GGT levels (Kristenson, 1983; Wallace, 1988; Israel, decreased GGT levels (Kristenson, 1983; Wallace, 1988; Israel,

1996)1996)

decreased sick days (Kristenson, 1983)decreased sick days (Kristenson, 1983)

decreased drinking and driving (Monti, 1999)decreased drinking and driving (Monti, 1999)

decreased scores on questionnaires regarding alcohol-related decreased scores on questionnaires regarding alcohol-related

problems (Marlatt, 1998)problems (Marlatt, 1998)

What We Know about Brief What We Know about Brief Motivational InterventionMotivational Intervention

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)

So if brief intervention works So if brief intervention works

and saves money…and saves money…

Why don’t ED providers screen, Why don’t ED providers screen,

practice brief intervention, and refer, practice brief intervention, and refer,

when indicated, to the substance when indicated, to the substance

abuse treatment system?abuse treatment system?