Interventions in Emergency Departments

Fortunately, we now know several truths, including that intervention works:

Brief intervention does work There is compelling evidence in the literature that screening and brief intervention (SBI) for alcohol problems does work.(2) A recent evidence-based review on SBI revealed 39 published studies including 30 randomized controlled and 9 cohort studies. A positive effect was demonstrated in 32 of these studies.(3) Multiple studies have demonstrated the efficacy of brief intervention in a variety of settings, including general populations, primary care,(4) emergency departments (5, 6, 7, 8) and inpatient trauma centers. (9)

The emergency department visit is an opportunity for intervention(10) Patients presenting to the ED are more likely to have alcohol-related problems than those presenting to primary care. Cherpitel(11) recently compared patients presenting to an ED with those presenting to a primary care setting in the same metropolitan area. She found that ED patients were one and a half to three times more likely to report heavy drinking, consequences of drinking, alcohol dependence, or ever having treatment for an alcohol problem, than patients presenting to a primary care clinic. In addition, the ED visit offers a potential “teachable moment” due to the possible negative consequences associated with the event.(12, 13)

Linking patients immediately to services has proven to be successful As early as 1957 Chafetz(5) reported that 65% of patients with alcohol dependence who were directly referred to an alcohol clinic from the ED kept their initial appointment compared to 5.4% of the control group. Bernstein(8) found that 50% of patients with alcohol and drug dependence in Project ASSERT reported follow-up with the treatment referral. Recently, another institution using Project ASSERT(14) reported similar positive results. Of the 719 patients who received a direct referral for a specialized alcohol and drug treatment program during a one year period of time, 41% were contacted. Of these, 80% made contact with the treatment facility and 78% enrolled.

BRIEF INTERVENTION

Brief interventions are short counseling sessions that can be as short as 5 minutes.(16) They often incorporate the six elements proposed by Miller and Sanchez summarized by the acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy and self-efficacy. ED DIRECT is an acronym that incorporates these concepts. For “at-risk” or “harmful” drinkers that are not dependent, goal setting within safe limits, discharge instructions and a referral to primary care is all that may be needed. For those patients who are dependent or that you are unsure of their position along the spectrum of alcohol problems, the brief intervention is a negotiation process to seek further assessment and referral to a specialized treatment program.

REFERRAL to AVAILABLE RESOURCES

Each facility must develop their own resource list for their community. Surprisingly there are often more referral sources than one would expect. See www.addictionsresources.com and www.alcoholismresources.com for more information on resources in your area.

REFERENCES

Harwood HJ. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods and Data. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism, 2000.
Wilk AI, Jensen NM, Havighurst TC. Meta-anaylsis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med. 1997;12(5): 274-83.
D’Onofrio G, Degutis LC. A review of screening and brief intervention for alcohol problems: Implications for Emergency Medicine Practice. Acad Emerg Med (in press).
Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA. 1997;277:1039-45.
Chafetz ME, Blane HT, Abram HS, Golner J, Lacy E, McCourt WF, Clark, E, Meyers W. Establishing treatment relations with alcoholics. J Nerv Ment Dis 1962;134:395-409.
Wright S, Moran L., et al. Intervention by an alcohol health worker in an accident and emergency department. Alcohol & Alcoholism. 1998;33:651-656.
Monti P, Spirit A. et al. Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. J Consult Clin Psychology. 1999;67:989-994.
Bernstein E, Bernstein J, Levenson S. Project ASSERT-An ED based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Ann Emerg Med. 1997;30:181-189.
Gentillelo L, Donovan DM, Dunn CW, Rivara FP. Alcohol interventions in trauma centers: current practice and future directions. JAMA. 1995;274:1043-1048.
D’Onofrio G, Bernstein E, Bernstein J, Woolard RH, Brewer PA, Craig SA, Zink BJ. Patients with alcohol problems in the emergency department Part1: Improving detection. Acad Emerg Med 1998;5:1200-1209.
Cherpitel CJ. Drinking patterns and problems: a comparison of primary care with the emergency room. Substance Abuse. 1999;20:85-95.
Longabaugh R, Minugh PA, Nirenberg TD, Clifford PR, Becker B, Woolard R. Injury as a motivator to reduce drinking. Acad Emerg Med. 1995;2:817-825.
Cherpitel CJ. Drinking patterns and problems and drinking in the event: an analysis of injury by cause among casualty patients. Alcohol Clin Exp Resl 1996;20:1130-1137.
D’Onofrio G, Mascia R, Razzak J. Degutis LC. Utilizing health promotion advocates for selected health risk screening and intervention in the ED. Acad Emerg Med 2001;8:543 (abstract).
Cherpitel CJ. Screening for alcohol problems in the emergency department. Ann Emerg Med. 1995;26:158-66.
D’Onofrio G, Bernstein E, Bernstein J, Woolard RH, Brewer PA, Craig SA, Zink BJ. Patients with alcohol problems in the emergency department Part2: Intervention and referral. Acad Emerg Med. 1998;5:1210-7.

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