brief intervention and referral to treatment emergency medicine
TRANSCRIPT
Brief Intervention and Brief Intervention and Referral to TreatmentReferral 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
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
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
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
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
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
Drinking Patterns in the U. S.
Dependent 5%
At Risk or Problem20%
Source: National Longitudinal Alcohol Epidemiologic Survey, 1992
Low Risk 35%
Abstain 40%
Prevention and Intervention
ABSTAINERS & MILD DRINKERS
(70%)
MODERATE(20%)
at risk drinkers
SEVERE (10%)
Primary Prevention
Brief Intervention
Specialized Treatment
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
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
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
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
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
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
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
Social Morays Social Morays
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
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
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
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
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
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?
Stages of Change Model
Pre-Contemplation Contemplation
Maintenance
Action
Preparation
Prochaska & DiClemente, 1986
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