1. Alcohol and Tobacco Screening, Brief Intervention, Referral and Treatment (SBIRT) for Emergency Room Patients Mary K. Murphy, Ph.D. 1 David Lounsbury, Ph.D. 2 Albert Einstein College of Medicine Department of Emergency Medicine 1, 2 & Epidemiology and Population Health 1 Tobacco Think Tank Meeting 10/12/10

2. PURPOSE

3. A Major Public Health Problem Alcohol and tobacco are among the most widely used addictive drugs Alcohol and tobacco are among the most widely used addictive drugs Both contribute significantly to preventable morbidity and mortality Both contribute significantly to preventable morbidity and mortality Co-use of alcohol and tobacco further heightens the risk of disease and death Co-use of alcohol and tobacco further heightens the risk of disease and death Alcohol consumption  injuries and deaths from motor vehicle accidents, falls, drowning, fires and burns, and violence Alcohol consumption  injuries and deaths from motor vehicle accidents, falls, drowning, fires and burns, and violence Tobacco consumption  #1 cause of preventable morbidity and mortality in US Tobacco consumption  #1 cause of preventable morbidity and mortality in US

4. Rationale for Integrated Treatment Services Among at-risk and dependent drinkers, smoking prevalence is about 70% compared to 24% for non-smokers Among at-risk and dependent drinkers, smoking prevalence is about 70% compared to 24% for non-smokers People who drink are 3x more likely to smoke People who drink are 3x more likely to smoke Alcohol consumption has been identified as a trigger for smoking and relapse to smoking Alcohol consumption has been identified as a trigger for smoking and relapse to smoking Highest risk group- multiplicative risk increase, possible biological synergy Highest risk group- multiplicative risk increase, possible biological synergy

5. Uncertainty about Combined Treatment Strategies We don’t know how much of what kind of treatment for which kind of co-user will work We don’t know how much of what kind of treatment for which kind of co-user will work What do patients want to address first? Their alcohol or tobacco use? What do patients want to address first? Their alcohol or tobacco use? How much of what kind of treatment (counseling and/or pharmacotherapy) is needed to reduce their drinking to a safe level? Or to quit smoking? How much of what kind of treatment (counseling and/or pharmacotherapy) is needed to reduce their drinking to a safe level? Or to quit smoking? Phone, face-to-face, e-mail/texting, a combination. What modality is most effective? Phone, face-to-face, e-mail/texting, a combination. What modality is most effective? How does gender, race, ethnicity, age, years of use and/or dependency matter? How does gender, race, ethnicity, age, years of use and/or dependency matter?

6. PROPOSED SPECIFIC AIMS

7. Aim 1: Identify and modify existing treatment manuals for motivational counseling interventions to be used with a diverse group of ED patients who are current smokers and or at- risk drinkers, eliciting feedback from experts in the fields of motivational interventions and emergency medicine, research staff and study participants. Aim 1: Identify and modify existing treatment manuals for motivational counseling interventions to be used with a diverse group of ED patients who are current smokers and or at- risk drinkers, eliciting feedback from experts in the fields of motivational interventions and emergency medicine, research staff and study participants.

8. Aim 2a: Utilize a computer-based screening program to assess the prevalence and severity of alcohol and tobacco use among a diverse, urban population during an emergency department visit. Aim 2a: Utilize a computer-based screening program to assess the prevalence and severity of alcohol and tobacco use among a diverse, urban population during an emergency department visit.

9. Aim 2b: Evaluate the delivery of a brief intervention for at risk alcohol users and smokers initiated during an ED visit followed by telephone counseling conducted over a 2 month period post emergency department visit. Aim 2b: Evaluate the delivery of a brief intervention for at risk alcohol users and smokers initiated during an ED visit followed by telephone counseling conducted over a 2 month period post emergency department visit.

10. CONTEXT

11. Emergency Dept Patients Profile High prevalence of unmet substance abuse treatment need among adult ED patients (Rockett, 2005) 1.5 - 3.0 times more likely to report heavy drinking than primary care patients (Cherpitel, 1999) Between 9% and 46% of ED patients have recently consumed alcohol and a significant number of the 32 million ED injury visits are alcohol-related (Bernstein, E., 1997) Approximately 25% use tobacco; 12% are at-risk drinkers and smoke (Murphy pilot project)

12. Methodological approach SBIRT (SAMHSA public health approach) SBIRT (SAMHSA public health approach) Comprehensive brief intervention approach that delivers early intervention and treatment services to people with substance use disorders and people who are at-risk of developing these disorders Comprehensive brief intervention approach that delivers early intervention and treatment services to people with substance use disorders and people who are at-risk of developing these disorders Goal  early intervention with at-risk substance users before more severe consequences occur Goal  early intervention with at-risk substance users before more severe consequences occur

13. Screening, Brief Intervention, Referral & Treatment (SBIRT) Goals NIAAA safe drinking guidelines PHS guideline for treating tobacco use and dependence (5As and 5Rs) Apply standardized screening instruments Provide: Normative feedback Treatment resources when indicated (i.e., above safe drinking limits and/or currently using tobacco)

14. Prior SBIRT Research A recent systematic review of 39 SBIRT alcohol studies (predominantly RCTs) targeting alcohol users found that such interventions are effective in facilitating significant reductions in alcohol consumption (D’Onofrio & Degutis 2002) Challenge: SBIRT most effective with primary care pts, ED injury pts, decrease neg consequences assoc drinking such as DUI- inconsistent alc reductions w/in ED pop (Havard et al 2008). Why? Studies note computers should be utilized in SBIRT interventions (Hungerford & Pollock, 2003; Bernstein, SL et al 2007)

15. CASI Pilot Cross sectional design Cross sectional design Bilingual RAs 24/7 ED coverage Bilingual RAs 24/7 ED coverage Medically stable, > 1 hr since triage, AO X3, > 21 yo, No SI/HI, informed consent, no gross intoxication, pass computer screen Medically stable, > 1 hr since triage, AO X3, > 21 yo, No SI/HI, informed consent, no gross intoxication, pass computer screen Computer program provided by Boston University School of Public Health / Join Together syndicated website (www.alcoholscreening.org) Eng / Span Computer program provided by Boston University School of Public Health / Join Together syndicated website (www.alcoholscreening.org) Eng / Spanwww.alcoholscreening.org AUDIT, normative feedback, alcohol education, treatment referral, debriefing session (10-15 min) AUDIT, normative feedback, alcohol education, treatment referral, debriefing session (10-15 min)

17. Patient acceptance of CASI program% Correctly identified their alcohol risk level after participating in the CASI program (comprehension) 91 Reported the program was easy to use93 Liked using the computer program89 Felt comfortable using computer to receive this information 92 Felt others would be helped by this program92 Would be willing to participate in future computer- based study during an ED visit 78 Found information useful to them82 Learned information would not have asked their doctor 46

18. METHODS

19. R21 Proposed Design 1. Computer assisted self interview (CASI) in ED 2. Motivational interviewing (MI) counseling intervention in ED by MA level counselor (goal to encourage treatment engagement & promote reduction in drinking / smoking) 3. 2 month follow up period 4. Timepoints: In ED (in person) followed by 2 weeks, 1 month and 2 months post ED (phone)

20. Staffing, Training and Supervision Bilingual Research Assistants staff ED 24/7 – will complete baselines & follow up assessments Bilingual Research Assistants staff ED 24/7 – will complete baselines & follow up assessments Two trained Masters Level study therapists will be hired to conduct MI phone counseling sessions Two trained Masters Level study therapists will be hired to conduct MI phone counseling sessions BNI-ART Institute at Boston University will provide therapist training BNI-ART Institute at Boston University will provide therapist training Audio taped counseling sessions will be reviewed for reliability & protocol fidelity Audio taped counseling sessions will be reviewed for reliability & protocol fidelity

21. CASI Instruments and MI Assessment Guides Emergency Room Patient Demographics Emergency Room Patient Demographics General Health (Questionnaire) General Health (Questionnaire) Alcohol Use Disorders Identification Test Alcohol Use Disorders Identification Test Fagerstrom Test for Nicotine Dependence Fagerstrom Test for Nicotine Dependence CASI Satisfaction (Questionnaire) CASI Satisfaction (Questionnaire) Who, What, When, Where Why (5Ws) Questionnaire Who, What, When, Where Why (5Ws) Questionnaire Medical Problems and Prior Treatment Questionnaire Medical Problems and Prior Treatment Questionnaire

22. Proposed Recruitment Strategy Approach approximately n=1,000 ED patients Approach approximately n=1,000 ED patients Identify approx 120 alc / tob co-users (our main interest) Identify approx 120 alc / tob co-users (our main interest) Possible designs: Possible designs: 1. Randomize half patients to MI intervention 2. Deliver intervention to ALL patients; no control group 3. Alternate multifactorial design: Alc only, Tob only, Alc+tob no interv (different from all of the above, allows for multiple comparisons & doubles the sample size)

23. Outcomes/Endpoints Alcohol: Past 30 days mean number of standard drinks per week; drinking within NIAAA guidelines; change in stage of change Alcohol: Past 30 days mean number of standard drinks per week; drinking within NIAAA guidelines; change in stage of change Tobacco: Number of quit attempts; smoking status; change in stage of change Tobacco: Number of quit attempts; smoking status; change in stage of change Community service access: Number of services contacted; number of contacts per service; satisfaction with services received Community service access: Number of services contacted; number of contacts per service; satisfaction with services received

24. ADDRESSING REVIEWER COMMENTS

25. “Proposed treatment has already demonstrated less than sufficient effectiveness in smokers in the ED, there is not a compelling case made in the grant that combining the 2 interventions for one multiply-diagnosed population will be more effective than the mono therapy” “Proposed treatment has already demonstrated less than sufficient effectiveness in smokers in the ED, there is not a compelling case made in the grant that combining the 2 interventions for one multiply-diagnosed population will be more effective than the mono therapy” Does it make clinical sense to combine these two interventions?

26. Aims are too ambitious “First 2 aims are feasible but third aim of conducting an RCT is overreaching, timeline does not allow for 5 follow ups”. “First 2 aims are feasible but third aim of conducting an RCT is overreaching, timeline does not allow for 5 follow ups”. R21: Encourages new, exploratory and developmental research projects by providing support for the early stages of project development. Sometimes used for pilot and feasibility studies. R21: Encourages new, exploratory and developmental research projects by providing support for the early stages of project development. Sometimes used for pilot and feasibility studies.