Module 3 Brief Intervention

3-2 Hhhh ADVISE APPROPRIATE ACTION FOLLOW UP - Supportive Care ASSESS Academic Social Behavioral Medical ASK Quantity/Frequency Binge CAGE AUDIT Brief Intervention Motivational Interview Referral Step 1 Step 2 Step 3 Step 4 3-2

3-3 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

3-4 Brief Intervention or Brief Talk Therapy Commonly used by clinicians to talk to patients about health issues or medication compliance Not unique to the alcohol field Designed for use in busy clinical settings Generally 5-10 minute duration

3-5 Brief Intervention or Brief Talk Therapy (continued) Includes motivational interviewing and Cognitive Behavioral Therapy (CBT) techniques More clinician-centered than client-centered therapy Clinician shares concerns with student and tries to convince student to decrease alcohol use

3-6 Brief Intervention or Brief Talk Therapy (continued) Uses an empathic, non-confrontational style Offers patient choices Emphasizes patient responsibility Conveys confidence in patient's ability to change

3-7  Conduct an assessment: “Tell me about your drinking.” “What do you think about your drinking?”  Provide direct clear feedback: "As your doctor/therapist, I am concerned about how much you drink and how it is affecting your health." Brief Intervention or Brief Talk Therapy (continued)

3-8  Establish a treatment contract through negotiation and goal setting: "You need to reduce your drinking. What do you think about cutting down to three drinks 2-3 times per week?“  Apply behavioral modification techniques: "Here is a list of situations when students drink and sometimes lose control of their drinking.” Brief Intervention or Brief Talk Therapy (continued)

3-9  Ask patients to review a self-help booklet and complete diary cards: “I would like you to review this booklet and bring it with you at your next visit. I’d also like you to write down how much you drink on these diary cards.”  Set up a continuing care plan for nurse reinforcement phone calls and clinic visits. Brief Intervention or Brief Talk Therapy (continued)

3-10 Brief Intervention Studies in College Students Marlatt et. al heavy drinking college freshmen recruited at the University of Washington Recruitment occurred via self-report questionnaire completed by incoming students Intervention delivered by research staff No involvement of primary care clinicians Follow up at 6, 12 and 24 months

3-11 Brief Intervention Studies in College Students Marlatt et. al (continued) Intervention consisted of self-monitoring personalized feedback at year 1 mail feedback at year 2 Experimental group drank significantly less and had fewer self-reported consequences than the control group

3-12 Brief Intervention Trials Conducted in Young Adults Monte et. al persons age recruited from hospital emergency departments based on an alcohol-related accident Subjects randomized to brief motivational interview or standard care Intervention consisted of a minute motivational interviewing session with a counselor Outcome - subjects randomized to the intervention group had fewer negative consequences, reduced drunk driving arrests, and fewer traffic violations

3-13 Project TrEAT Fleming, 2002 Trial of Early Alcohol Treatment 64 physicians, 17 sites 17,695 screened 1,705 assessed 774 enrolled (n=225 persons years old) 392 experimental 382 control Follow-up: 12 months 723 (93.4%) 48 months 643 (83.1 %)

Project TrEAT (continued) 3-14

Project TrEAT (continued) 3-15

Project TrEAT (continued) 3-16

Project TrEAT (continued) 3-17

Month TrEAT Data: Benefit-Cost Analysis TreatmentControl (n=392)(n=382) Medical Use Emergency department visits302376* Days of hospitalization * Motor Vehicle Events Crash with fatalities 0 2 Crash with non-fatal injuries 2031 Crash with property damage only 6772 Operating while intoxicated 2525 Other moving violations * Adjusted to equate patient-years

Month TrEAT Data: Benefit-Cost Analysis TreatmentControl (n=392) (n=382) Legal Events Assault/battery/child abuse 8 11 Resist/obstruct officer/disorderly 8 6 Controlled substance/liquor violation 2 11 Criminal damage/property damage 2 1 Theft/robbery 3 3 Other arrests 5 9

48-Month TrEAT Data: Benefit-Cost Analysis Net Benefits & Benefit Cost Ratios (1993 dollars) PerspectiveCost per Benefits perBenefit-costNet BenefitP-value patientpatientratio (95% CI)(95% CI) Medical$166 $ $ (0.6, 8.0) ($-71, $1164) Societal$205 $7,98539 $ (excl. life yrs)(5.4, 72.5)($894, $14,668) Societal$205$11,65996 $19, (incl. life yrs)(-33, 225)($-7165, $46,044) 3-20

3-21 What We Know  Brief Intervention can reduce alcohol use for at least 12 months  Effect size is similar for men and women  Effects are similar for persons over age 18

3-22 What We Know (continued) Reduction in utilization events Cost savings Improved health status

3-23 BI appears to reduce alcohol-related harm 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 (continued)