Alcohol problems are prevalent in EDs nationwide, often manifesting when individuals seek medical care for acute illnesses and injuries relating to alcohol. Hazardous and harmful drinking has emerged as a major focus of screening, brief intervention, and referral to treatment efforts in various healthcare settings. Hazardous and harmful drinking has been defined as more than 14 drinks a week or more than four drinks per occasion for men. For women, the thresholds have been defined as more than seven drinks a week or more than three per occasion.
While some evidence supports the usefulness of brief interventions for alcohol in primary care and inpatient trauma settings, the data from ED settings are less clear. “It is difficult to compare and assess studies of alcohol screening and interventions in the ED because of several factors,” explains Gail D’Onofrio, MD, FACEP. “Screening tools vary and different levels of severity of drinking may have been included, such as hazardous (at-risk) drinking to dependent drinkers. Also, enrollment may have been limited to certain chief complaints (eg, injury), while others screened participants universally. Other analyses may have varied in length and quality.”
Examining a Brief Alcohol Intervention
In the March 27, 2012 Annals of Emergency Medicine, Dr. D’Onofrio and colleagues had a study published in which they assessed the impact of an emergency practitioner-based intervention on alcohol consumption in 740 patients who were classified as hazardous and harmful drinkers. A brief negotiation interview (BNI)—which takes only about 7 minutes to perform—was administered to 298 patients. The BNI included:
1. Raising the subject of alcohol.
2. Providing feedback by reviewing screening data and connecting alcohol and the visit/ illness or injury.
3. Reviewing guidelines for low-risk drinking.
4. Enhancing motivation by asking patients how likely they were to change their drinking behavior and exploring why a lower number was not chosen.
5. Negotiating a drinking goal.
An additional 295 patients received the BNI with a “booster” phone call a month later by a trained primary care nurse. If patients reached low-risk drinking levels, their methods for reaching these levels were reinforced and relapse prevention was discussed. If not, an attempt was made to negotiate a new agreement or to consider changes in the future. Coping skills and stressors were assessed, and motivational strategies for change were offered. The remaining 148 patients in the study received standard care.
Promising Results of the BNI Intervention
After receiving the BNI intervention, hazardous and harmful drinkers identified in the ED were more likely to reduce their alcohol consumption and cut down on binge drinking. They were also less likely to drive after drinking three or more alcoholic beverages (Table). Patients who received the BNI intervention reduced their average number of drinks from 19.8 per week at baseline to 14.3 at 12 months. The reduction in 28-day binge drinking episodes for the BNI group was 7.2 episodes at baseline to 5.1 episodes at 12 months.
The study also showed that the interventions had a significant effect on both younger and older adults with regard to the number of drinks per week and the number of bingeing episodes per month (Figure). The BNI with booster had even greater reductions but offered no significant benefit over the BNI performed at the initial ED visit. Rates of driving after drinking declined from 38% at baseline to 29% at 12 months in the BNI group. Corresponding percentages for the BNI plus booster group were 39% and 31%, respectively.
Changing the Treatment Paradigm for Alcohol Misuse
Dr. D’Onofrio notes that emergency physicians see the tragic effects of alcohol misuse in the ED on a daily basis. “We treat acute injuries and illnesses routinely. By establishing that the BNI is an effective intervention, there is hope that more EDs will help shift the treatment paradigm. Greater efforts are needed to include screening, brief interventions, and referral to treatment for all people with all levels of drinking severity, much like we’ve seen with hypertension and HIV in the ED.”
Advocacy groups have introduced accreditation standards for institutions and have established training programs for physicians and residents in alcohol screening and brief interventions. “The BNI intervention from our study can serve as a good framework for EDs,” says Dr. D’Onofrio, “but modifications may be necessary since institutions typically have different needs and capabilities. That said, these efforts are important because emergency physicians can help change drinking behaviors in the future, which in turn may improve public health.”
D’Onofrio G, Fiellin DA, Pantalon MV, et al. A brief intervention reduces hazardous and harmful drinking in emergency department patients Ann Emerg Med. 2012 Mar 27 [Epub ahead of print]. Available at http://www.annemergmed.com/webfiles/images/journals/ymem/FA-GDOnofrio.pdf.
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