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

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Presentation on theme: "The Rationale for Screening, Brief Intervention and Referral in the Medical Setting."— Presentation transcript:

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

2 WHY EARLY INTERVENTION FOR HIGH-RISK AND DEPENDENT DRINKING? High-risk and dependent drinking reduces quality and length of life, and is costly to individuals and society.High-risk and dependent drinking reduces quality and length of life, and is costly to individuals and society. The medical encounter is too important a prevention opportunity to miss.The medical encounter is too important a prevention 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.

3 Alcohol & Other Drug Dependence, A Chronic Illness <30% of patients with adult onset asthma, HTN, diabetes adhere to prescribed diet and/or behavioral changes<30% of patients with adult onset asthma, HTN, diabetes adhere to prescribed diet and/or behavioral changes 50% of adults with these chronic conditions experience recurrence of sx yearly, requiring additional medical care50% of adults with these chronic conditions experience recurrence of sx yearly, requiring additional medical care 50-60% of patients discharged from substance abuse treatment are abstinent at 1 year50-60% of patients discharged from substance abuse treatment are abstinent at 1 year As in other chronic diseases, poor adherence and relapse is predicted by low SES, co-morbid psych conditions and lack of family and social supportsAs in other chronic diseases, poor adherence and relapse is predicted by low SES, co-morbid psych conditions and lack of family and social supports Substance abuse should be insured, monitored, treated and evaluated like other chronic diseasesSubstance abuse should be insured, monitored, treated and evaluated like other chronic diseases McClellan AT, Lewis DC, et al. JAMA 2000; 284:

4 Health Care Settings Using Brief 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 ServicesPsychiatric Services Student Health CentersStudent Health Centers Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation

5 Public Health Paradigm The primary goal of brief intervention is to –reduce alcohol use to low-risk levels –encourage abstinence in persons who are alcohol-dependent

6 BRIEF INTERVENTION: A REVIEW Chafetz et al, 1961Chafetz et al, 1961 –Randomized, controlled trial (n=200) –65% of those receiving brief intervention in the MGH ED kept a subsequent appointment for specialized treatment compared to 5% of controls. –40% kept 5 appointments. (Establishing treatment relations with alcoholics. J Nerv Ment Dis 1962; 134: )

7 ALCOHOL TREATMENT WORKS McClellan (1982) showed treatment effects at 6 months f/u on ASI measures of alcohol use, drug use, family interactions, work, legal and psychological functionMcClellan (1982) showed treatment effects at 6 months f/u on ASI measures of alcohol use, drug use, family interactions, work, legal and psychological function –54% reduction in drinking days –67% reduction in days intoxicated –41% of participants abstinent for 30 days prior to follow-up –151% increase in income McClellan TA, Luborsky L, O’Brien CP, et al. Is treatment for substance abuse effective? JAMA 1982; 247:

8 BRIEF INTERVENTION: A REVIEW Bien TH, Miller WR, Tonigan JS, 1993Bien TH, Miller WR, Tonigan JS, 1993 –meta-analysis (n=6000) 13 randomized trials; 32 controlled trials –more effective than no counseling –as effective as traditional therapy in 11/13 trials Brief intervention for alcohol problems: A review. Addiction 1993; 88: Addiction 1993; 88:

9 Alcohol Intervention in a Trauma Center to Reduce Injury Recurrence Randomized, controlled trialRandomized, controlled trial Level 1 Trauma Center patients screened with blood alcohol, GGT, and Michigan Alcoholism Screening Test (SMAST)Level 1 Trauma Center patients screened with blood alcohol, GGT, and Michigan Alcoholism Screening Test (SMAST) 772 positives randomized to intervention or control772 positives randomized to intervention or control Re-injury detected by computer search of statewide ED and hospital discharge recordsRe-injury detected by computer search of statewide ED and hospital discharge records Alcohol use assessed at 6 and 12 monthsAlcohol use assessed at 6 and 12 months Gentilello, Rivara et al. Ann Surg 1999; 230:

10 Trauma 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 both groups (NS)at 6 months, decreases in both groups (NS) at 12 months, reduced alcohol consumptionat 12 months, reduced alcohol consumption –down by 22 drinks per week in intervention group –down 6.7 drinks per week in control group reduced number of injuries requiring ED or admissionreduced number of injuries requiring ED or admission –down 47% in the intervention group vs controls Gentilello, Rivara et al. Ann Surg 1999; 230:

11 D’Onofrio & Degutis (Acad Emerg Med) Review of 39 clinical trialsReview of 39 clinical trials –30 (RCT) –9 (Cohort) 32 studies reveal positive effect of BI32 studies reveal positive effect of BI

12 Brief Intervention for Harm Reduction With Alcohol + Older Adolescents in a Hospital ED Population: 18 to 19 year olds (n = 94)Population: 18 to 19 year olds (n = 94) Site: Rhode Island Hospital PEDSite: Rhode Island Hospital PED Intervention: motivational intervention by masters level practitioners, primarily social workersIntervention: motivational intervention by masters level practitioners, primarily social workers Outcomes: alcohol consumption, drinking and driving, alcohol related problems, injuries, moving violations (DMV)Outcomes: alcohol consumption, drinking and driving, alcohol related problems, injuries, moving violations (DMV) Design: RCT with 3 and 6 month f/uDesign: RCT with 3 and 6 month f/u Monti P, et al. J Consult Clin Psychol 1999; 67:

13 Monti et al. Results of Brief Motivation with 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 control groupMoving violations: 3% in the intervention group vs 26% in the control group Similar reductions in alcohol use despite differences in alcohol related consequencesSimilar reductions in alcohol use despite differences in alcohol related consequences –having driven after drinking ( p<0.05) –having had alcohol involved in an injury (p<0.01) –to have had alcohol-related problems (p<0.05)

14 Evaluating the effects of a brief motivational intervention for injured drinkers in the ED. Longabaugh R, Woolard RE, Nirenberg TD, et al. J Stud Alcohol 2001 n=539 injured ED patients with an AUDIT score of >8 or alcohol in system at the time of injuryn=539 injured ED patients with an AUDIT score of >8 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 brief intervention with booster (BIB)3 groups: standard care vs brief intervention vs 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 to BIBPts with history of hazardous drinking responded to BIB

15 COST-BENEFIT ANALYSIS OF BRIEF MOTIVATION Fleming MF, et al. Medical Care 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 –$228,071 avoided costs in motor vehicle crashes and crime –5.6 to 1 benefit to cost ratio –$6 savings for every $ invested

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17 Project ASSERT: Boston Medical Center ED Follow-up at Days (n=182) Mean AUDIT Scores: 68% Reduction in Alcohol Use

18 The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. There was substantial evidence that MI is an effective substance abuse intervention method when used by clinicians who are non-specialists in substance abuse treatment, particularly when enhancing entry to and engagement in more intensive substance abuse treatment treatment- as-usual.There was substantial evidence that MI is an effective substance abuse intervention method when used by clinicians who are non-specialists in substance abuse treatment, particularly when enhancing entry to and engagement in more intensive substance abuse treatment treatment- as-usual. Dunn C, Deroo L, Rivara FP. Addiction 2001; 96:

19 The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials Motivational interviewing (MI) was equivalent to other active treatments and yielded moderate effects (from.25 to.57) compared with no treatment and/or placebo for problems involving alcohol, drugs, and diet and exercise.Motivational interviewing (MI) was equivalent to other active treatments and yielded moderate effects (from.25 to.57) compared with no treatment and/or placebo for problems involving alcohol, drugs, and diet and exercise. MI results: 51% improvement rate, a 56% reduction in client drinking, and moderate effect sizes on social impact measures (d=0.47).MI results: 51% improvement rate, a 56% reduction in client drinking, and moderate effect sizes on social impact measures (d=0.47). Burke BL, Arkowitz H, Menchola M. J Consult Clin Psychol 2003; 71:

20 JOIN TOGETHER 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 Project ASSERT - New Haven CNProject ASSERT - New Haven CN –3600 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

21 BI appears to reduce alcohol-related harm  reduces alcohol use for at least 12 months  similar effect size for men and women  decreased GGT levels (Kristenson, 1983; Wallace, 1988; Israel, 1996)  decreased sick days (Kristenson, 1983)  decreased drinking and driving (Monti, 1999)  decreased scores on questionnaires regarding alcohol-related problems (Marlatt, 1998) What We Know about Brief Motivational Intervention

22 Nation’s Public Health Agenda: Healthy People 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)

23 So if brief intervention works and saves money… Why don’t ED providers screen, practice brief intervention, and refer, when indicated, to the substance abuse treatment system?


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