Brief interventions to address substance use among patients presenting for emergency services in Cape Town, South Africa Katherine Sorsdahl

Presentation Overview 1. Present the rationale for brief interventions in emergency departments. 2. Present Project STRIVE and preliminary findings

Rational for Brief Interventions in Emergency Departments Close to half of the individuals presenting with injuries at emergency rooms in the province have been using AODs (Plüddemann et al, 2004; Parry et al., 2004). Most alcohol-related injuries do not involve people who are dependent on alcohol. Emergency departments are the ideal setting for screening and brief intervention to occur, as they are able to take advantage of the “teachable moment”.

What is a brief intervention A client-centred approach that focuses on changing risk behaviour. Refers to any therapeutic or preventive consultation of short duration undertaken by a health professional who is not usually a specialist in addiction treatment. The interventions may involve 1 to 5 sessions of 5 to 60 min.

Evidence for the Effectiveness of Brief Interventions Studies conducted in primary care facilities have generally found SBIs to be effective for reducing alcohol consumption and related harms (Pilowsky & Wu, 2012), while studies of SBIs conducted in ED settings have resulted in mixed findings (Crawford et al., 2004; Daeppen et al., 2007). There is little research on the effectiveness of SBIs for reducing illicit drug use among ED patients All these studies were conducted in developed country settings.

STRIVE (Substance use and Trauma InterVEntion ) AIM: To address gaps in current services by testing two brief, evidence-based interventions for risky alcohol and drug use among adults at 3 emergency departments.

Objectives of STRIVE 1.To screen patients presenting at emergency services for alcohol and other drug (AOD) use 2.To administer one of two brief interventions (ASSIST-linked Brief Intervention or MI modified problem solving therapy (PST) to patients presenting at these emergency services. 3.To compare the effectiveness of these two interventions against a control group (psychoeducation only) on AOD outcomes and the feasibility of implementing these interventions in real-world emergency settings.

Study Sites This pilot program was implemented at three 24 hour emergency room services: one in Elsies River and two in Khayelitsha. These public emergency room services were purposively selected by the Western Cape Department of Health as sites for the program because of the high proportions of alcohol-related homicides in these areas and the large numbers of patients treated for AOD-related injuries

Training of Peer Counsellors All of the peer counsellors originated from the communities served by the selected emergency services. Intervention training included: 18 hours of training in motivational interviewing training. 12 hours (1.5 days) of a training program in PST Other training Included: (i) alcohol and illicit drugs and the risks associated with substance use, (ii) using and scoring the ASSIST, (iii) ethics of research and importance of maintaining confidentiality and reporting adverse events, (iv) the intervention protocol, and (v) the process of referring patients for specialized care. To ensure intervention fidelity, peer counsellors participated in biweekly supervision and debriefing sessions.

Procedure Patients were approached for screening after they triaged and while they were waiting for a consultation with the attending doctor. To be eligible for the intervention program, participants had to be at least 18 years of and screen at moderate or high risk for substance-related problems using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). An interviewer-administered baseline questionnaire that takes approximately 45 minutes to complete was then administered to those patients who provided consent. Participants were followed up at 3 months *Participants were randomized to 1 of 3 intervention groups*

Interventions Control Group: This group did not receive a brief intervention, but was provided with a brochure providing information on the effects of alcohol and other drug use MI Group: An ASSIST-Linked Brief Intervention (WHO): This manually guided session occurred directly after completion of the screening interview and lasts between 20-30min. PST Group: Given ASSIST-Linked Brief Intervention (like MI group) participants then returned for 4 follow-up sessions approx. 1 week apart. The first of these follow-up sessions was about 60 minutes in duration while the remaining sessions lasted between 35 and 45 minutes. **Participants who screed high risk for substance-related problems were referred to specialist substance treatment facilities for further treatment**

Outcome Measures Primary outcome measure : Reduction in Substance Use (ASSIST) Secondary outcomes included: Depression: (CES-D) Frequency of substance use related injury Frequency of physical and verbal violence Frequency of police interaction Problem Solving Skills (SPSI-R:SF)

Statistical Analysis Multiple imputation was used to deal with the issue of missing data Baseline between-group differences in demographic data and pre-treatment measures were analysed with one-way ANOVAs and chi-square tests. Between-group changes in questionnaire scores were analysed using univariate ANCOVAs, assigning pre-treatment scores as the covariate. This approach is recommended as a robust and reliable statistical strategy for analysing the results of RCTs (Vickers, 2005b; Vickers, 2005a). Within-group changes in questionnaires were analysed using paired- samples t-tests.

Assessed for eligibility (n =2736) Excluded (n =2401) Did not meet inclusion criteria (n =2205) Refused to participate (n =104) No telephone contact (n =88) Did not return after seeing doctor (n=4) Randomized (n =335) Allocated to Control Group (n = 110) Received allocated intervention (n = 110) Allocated to MI intervention (n =113) Received allocated intervention (n = 113) Lost to follow up (n = 44) Unable to locate/unavailable Lost to follow up (n =44) Discontinued intervention (n = 22) Admitted to tertiary care (n=3) Unable to locate/unavailable (19) Analyzed (n = 66) Analyzed (n =46) Allocated to PST intervention (n =112) Received allocated intervention (n = 90) Lost to follow up (n = 43) Unable to locate/unavailable Analyzed (n = 70) Project STRIVE: Patient Flow Chart ENROLMENT ANALYSIS FOLLOW-UP ALLOCATION

Table 1: Baseline Characteristics of Participants Total (N=335)Control (N=110)MI (N= 113)PST (112) Age28 (18-75)27 (18-75)28 (18-65)28.5 (18-61)0.395 Gender0.378 Male N (%)218 (65.5)68 (62.4)71 (63.4)79 (70.5) Female N (%)115 (34.5)41 (37.6)41 (36.6)33 (29.5) Race0.621 Black N (%)195 (58.2)58 (53.7)68 (60.7) 69 (61.6) Coloured N (%)135 (40.7)49 (45.4)44 ( (37.5) White/Asian N(%)2 (0.6)1 (0.9) 0 Marital Status0.54 Single N (%)272 (82.9)91 (85.8)89 (80.2)92 (82.9( Married or attached N (%)56 (17.1)14 (14.2)22 (19.8)19 (17.1) Education0.788 Did not finish high school N (%)168 (50.1) 58 (52.7)56 (49.6)54 (48.2) Finished high school N (%)167 (49.9)52 ( (50.4)58 (51.8) Employment Employed N (%)147 (44.4) 45 (41.3)46 (40.7)56 (51.4)0.202 Unemployed N (%)184 (55.6) 64 (58.7)67 (59.3)53 (48.6) Presented with Injury Yes242 (72.2) 78 (70.9)82 (72.6)82 (73.2)0.925 No 93 (27.8) 32 (29.1)31 (27.4)30 (26.8) Intent of Injury Intentional N (%)1876.5)5 ( 49 (62.0)43 (52.4)46 (56.1) Non-intentional (N (%)57 (23.5) 20 (38.0)39 (47.6)36 (32.1) Under the influence when injured0.029* Yes N (%)197 (59.2)70 (63.6)72 (64.9)57 (50.9) No N (%)136 (40.8)40 (36.4)39 (35.1)55 (49.1) Substance Use Involvement Score (Total)19 (6-38)19 (7-35)19.75 (6.57)*18 (6-35)0.451 Alcohol (n=286)19 (10-38)19 (10-30)20 (10-38)17 (10-30)0.107 Dagga (n=24)20.5 (8-35)21.5 (12-27)18.09 (7.9)19.9 (10.1)*0.802 Cocaine (n=1)26 (26-26)n/a Methamphatemine (n=20)23.5 (6-35)19 (7-35)27 (17-32)23.3 (9.98)*0.436 Mandrax (n=4)9.5 (6-23)23 (23-23)6 (6-13)n/a

Results of ANCOVAs Control GroupMI GroupPST Group BaselineFollow-up Change from BaselineBaselineFollow-up Change from BaselineBaselineFollow-up Change from Baselinep-value Primary Outcome Total ASSIST19.18 (6.22)12.17 (7.16) (6.71)12.31 (7.87) (6.59)7.4 (5.9)-11.8p<0.001 Secondary Outcomes CES-D (Depression)**22.78 (5.27) (5.91) (7.84)16.92 (7.85) (6.85)12.91 (5.93)-13.08p<0.001 SPSI-F:SF-Social PPPO2.04 (0.62)2.20(0.66) (0.65)2.06 (0.65) (0.74)2.28 (0.63) NPO1.25 (0.75)1.14 (0.79) (0.73)1.16 (0.75) (0.94)1.33 (0.94) RPS1.96 (1.8)2.23 (0.91) (0.89)2.08 (0.88) (0.85)2.61 (0.71) ICS1.3 (0.83)1.00 (0.85) (0.73)1.05 (0.74) (0.83)0.79 (0.68) AS1.15 (0.82)1.08 (0.73) (0.71)1.10 (0.73) (0.78)1.01 (0.78) Verbal Arguments0.77 (1.06)0.76 (0.96) (0.94)0.23 (0.46) (1.34)0.65 (1.2)

Group Changes in ASSIST scores

Discussion It is not only feasible to screen large numbers of people presenting for emergency services for possible inclusion in a substance use risk reduction intervention, but that such an intervention program is urgently needed among this population. PST appears to be the most effective intervention for reducing substance and depression among at risk patients in ED settings. The data reported here also show no AOD use outcome differences between the MI and control group. The MI interventions significantly reduced verbal arguments among participants, but did result in diminished odds of alcohol-related injuries compared to the control group.

Acknowledgments Thanks to the Provincial Government of the Western Cape for funding and supporting the project! SAVI for funding the preliminary qualitative work Research Team: Bronwyn Myers, Tracey Naledi, Dan Stein, Susan Cleary, & Joanne Corrigal