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Screening, Brief Intervention and Referral to Treatment
Gail D’Onofrio MD, MSChief and Associate ProfessorSection of Emergency Medicine Yale University School of Medicine
Yale University School of Medicine
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Several Truths
• Treatment does work
• The ED/primary care visit is an opportunity for
intervention
• Timely referral is effective
• Practitioners are reluctant to screen and
intervene
• There are multiple barriers to SBI
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Why is SBI Important?
• Alcohol problems are common
• Overall economic cost $185
billion/1998
• Risk factor injury and illness
• Problems occur throughout the life
cycle
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Morbidity and Mortality
• >107,000 alcohol related deaths each year
• 1/3 of adult admissions are alcohol related
• Attributable risk factor for multiple illnesses
• Major risk factor for all categories of injury
– Problem drinkers have 2x injury events/yr and 4x as many hospitalizations for injury
– A single alcohol-related visit predicts continued problem drinking
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Trauma Prevention
• Regional trauma centers (RTCs) were developed 30 years ago
• Response to studies showing that 40% of injuries in U.S. could have been prevented if patient treated in facility with special expertise
• Today RTC’s reduced the preventable death rate 2-3%
• Conclusion: Any significant reduction in death rates will depend on progress in injury prevention
Gentilello, Annals of Surgery.1999:230:473
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Top 10 Leading Causes of Death in the United States for 2001, by Age Group
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Alcohol-Related Fatalities
0
2,500
5,000
7,500
10,000
12,500
15,000
17,500
20,000
22,500
25,000
27,500
82 84 86 88 90 92 94 96 98 00 02 04
Source: FARS
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BAC Levels for Alcohol Positive Drivers Involved in Alcohol-Related Fatal Crashes
Source: 2002 ARF FARS
.16 = Median and Mode BAC
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Drinking Patterns in the U. S.
Dependent 5%
At Risk or Problem20%
Source: National Longitudinal Alcohol Epidemiologic Survey, 1992
Low Risk 35%
Abstain 40%
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Universal Screening Widens The Net
ABSTAINERS & MILD DRINKERS
(70%)
MODERATE(20%)
at risk drinkers
SEVERE (10%)
Primary Prevention
Brief Intervention
Specialized Treatment
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Social Morays
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Stereotypic “Alcoholic”
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Role of the Practitioner
• Identify
• Assess
• Brief intervention
• Refer
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Screening
• Diagnostic tests
– Blood alcohol concentration (BAC)
– Saliva alcohol test
– Breathalyzer
– Adjunct tests (abnormal liver function tests,
macrocytic anemia)
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Screening
• Structured questionnaires– CAGE– TWEAK– AUDIT– Brief MAST– CRAFFT
• Quantity & frequency questions (NIAAA)
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Sensitivity & Specificity of Screening Instruments for Harmful & Dependent Drinkers
Screening Instrument
Harmful Dependent
S SP S SP
CAGE 75 88 76 90
TWEAK 87 86 84 86
AUDIT 85 88 83 90
BMAST 31 98 30 99
Breath Alcohol Analysis
20 94 20 94
Self Report 31 89 29 89
Cherpitel. Screening for Alcohol Problems in the Emergency Department. Ann Emerg Med. 1995; 26: 163-164
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ASK about Alcohol Use
• Consumption
• CAGE
Per week
Per occasion
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ASK Current Drinkers
• On average, how many days per week do
you drink alcohol?
• On a typical day when you drink, how
many drinks do you have?
• What’s the maximum number of drinks you
had on a given occasion in the last month?
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A Standard Drink
A standard drink is 12 grams of pure alcohol or:
• One 12-ounce bottle of beer or wine cooler
• One 5-ounce glass of wine
• 1.5 ounces of distilled spirits
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Screen Positive
Drinks per
week
Drinks per occasion
Men > 14 > 4
Women > 7 > 3
All Age >65 > 7 > 1
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Drinking Patterns: Rates and Risks Binge Drinking
The National Advisory Council on Alcohol Abuse and Alcoholism has recommended the following definition of “Binge Drinking”:
• A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gm% or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male) or 4 or more drinks (female) in about 2 hours.
• Binge drinking is clearly dangerous for the drinker and for society
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Drinking Patterns
% of US adults aged 18+
Abusewithout
dependence
Dependencewith or without
abuse
Exceeds daily limit< once a week
16% 1 in 8(12%)
1 in 20(5%)
Exceeds daily limitonce a week or more
3% 1 in 5(19%)
1 in 8(12%)
Exceeds bothweekly & daily limits
9% 1 in 5(19)
1 in 4(28)
Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
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ASK Current Drinkers
CAGE
C Cut DownA AnnoyedG GuiltyE Eye Opener
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Assessment: Level of Severity
• At risk
No current problems
• Experiencing problems
Medical
Behavioral
• Signs of dependence
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Assessment: Alcohol Dependence
ASK:
• Are there times when you’re unable to stop drinking?
• Does it take more drinks to get high?
• Do you feel a strong urge to drink?
• Do you change your plans to be able to drink?
• Do you drink early in the am to relieve the ‘shakes’?
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THE SSOT*
Beecher's Immediate and Faithful Self-examination of the Signs Of in Temperance
Ascertain whether any of the symptoms of intemperance are beginning to showthemselves upon you. And let not the consideration that you have never beensuspected, and have never suspected yourselves of intemperance, deprive youof the benefit of this scrutiny.
1) Are there then set times, days, and places, when you calculate always to indulge yourselves in drinking ardent spirits?
2) Do you stop often to take something at the tavern when you travel, and always when you come to the village, town, or city?
*Beecher, L. (1828). Six sermons on the nature, occasions, signs, evils, and remedy of intemperance. Boston, MA.
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THE SSOT (cont.)
3) Have you any friends or companions whose presence, when you meet them, awakens the thought and the desire of drinking?
4) Do any of you love to avail yourselves of every little catch and
circumstance among your companions, to bring out "a treat?"
5) Do you find the desire of strong drink returning daily, and at stated hours?
6) Do any of you drink in secret, because you are unwilling your friends or the world should know how much you drink?
7) Are you accustomed to drink, when opportunities present, as much as you can bear without any public tokens of inebriation?
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THE SSOT (cont.)
8) Do your eyes, in any instance, begin to trouble you by their weaknesses or inflammation?
9) Do any of you find a tremour of the hand coming upon you, and sinking of spirits, and loss of appetite in the morning?
10) Do the pains of a disordered stomach, and blistered tongue and lip, begin to torment you?
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Brief Intervention
• Short counseling sessions (5-45 minutes)
• Single or repeated sessions
• Performed by non-addiction specialists
• Contain advice and/or motivational
enhancement
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Brief Intervention
• At risk/problem drinkers– Advise to cut down
– Set goals
– Provide Primary Care follow-up
• Dependence– Advise to abstain
– Refer to treatment
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Stages of Change Model
Pre-Contemplation Contemplation
Maintenance
Action
Preparation
Prochaska & DiClemente, 1986
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A Disswasive from the Horrid and Beastly Sin of Drunkenness [Anonymous, 1705]
• “Drunkenness is a Sin which hath long been called a Voluntary Madness”
• “The means to keep from this beastly Sin, next to the frequent Use of fervent prayer is, carefully to avoid the Occasions and Temptations that are apt to betray us to it.”
• This Disswasive from Drunkenness is thus printed in half a Sheet of Paper, that it may be made up in the Form of a Letter, and directed to any Persons that are guilty of it.
Babor TF. J of Consulting & Clinical Psychology 1194;62:1127-1140
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Enhancing Motivation for Change: FRAMES
F eedback (personalized, non-judgmental)
R esponsibility (respect for autonomy)
A dvice (clear and timely)
M enu of options (what works for you?)
E mpathy (reflective listening)
S elf-efficacy (offer optimism and hope)
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General Principles for Negotiating Behavior Change
• Respect for autonomy of patients and their choices
• Readiness to change must be taken into account
• Ambivalence is common • Targets selected by the patient, not the expert• Expert is the provider of the information • Patient is the active decision-maker
Rollnick, 1994
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Brief Intervention
• Bien et al. (Addiction 1993)– 32 trials of BI in 14 nations– BI is more effective than no counseling, and often as
effective as more extensive treatment
• Wilk et al. (J Gen Intern Med 1997)– Pooled outcome data from 12 RCTs of BI – odds ratio 1.9 (95% CI 1.61-2.27) in favor of BI
• D’Onofrio & Degutis (Acad Emerg Med)
– Review of 39 clinical trials: 30 (RCT) & 9 (Cohort)
– 32 studies reveal positive effect of BI
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World Health Organization(Am J Pub Health 1996)
“A cross-national trial of brief interventions with heavy drinkers”• Multinational study in 10 countries (n=1,260)
• Interventions included simple advice, brief & extended counseling compared to control group
• Results: Consumption decreased– 21% with 5 minutes advice, 27% with 15 minutes
compared to 7% controls– Significant effect for all interventions
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Fleming et al. JAMA 1997;277:1039-1047
“Brief physician advice for problem alcohol drinkers: a randomized control trial in community-based primary care practices”
• BI in 17 practices with 64 physicians
• Intervention included: educational workbook,
(2) 15 minute visits one month apart, and
(2) nurse follow-up calls, 2 weeks after the visit
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Fleming
• Results at 12 months (n=723)
Consumption:
(I) 19.1 drinks/wk to 11.5 vs (C) 18.9 to 15.2
Episodes of binge drinking during prior 30 days:
(I) 5.7 to 3.1 vs (C) 5.3 to 4.2
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COST-BENEFIT ANALYSIS OF BRIEF MOTIVATIONFleming MF, et al. Medical Care 2000; 38:7-18.
• RCT (n=774)
• primary care practice, managed care setting
• problem drinkers
• economic cost of intervention = $80,210 ($205 each)
• economic 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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Monti et al, J Consulting and Clinical Psychology 1999
“Brief intervention for harm reduction with alcohol-positive older adolescents in an ED”
• 94 patients (18-19 years) were randomized• (I) group had a significant reduction in alcohol
use (p<.001) at 6 month f/u and were less likely to report:– 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)
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Gentilello et al. Annals Surgery1999;230:473-483
“Alcohol Interventions in a Trauma Center
as a Means of Reducing Risk of Injury Recurrence”
• Admitted injured patients who tested and/or screened positive for alcohol problems were randomized (n=732)
• Results at 12 months (54% follow-up rate):(I) alcohol consumption 21.8 drinks/week vs (C) 6.7
(p=0.03)
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Gentilello
• Reduction most apparent in mild-moderate drinkers: 21.6 drinks/week vs 2.3 drinks/week in controls (p<0.01)
• 47% reduction in new injuries requiring ED visit or readmission to the trauma service (p=0.07)
• 48% reduction in new injuries requiring hospitalization at 3-year follow-up
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Longabaugh R, et al. J Stud Alcohol 2001;62:806-816
• n=539 injured ED patients with an AUDIT score of >8 or BAC > 0.03
mg/dl or reported ingestion 6 hours prior to injury
• 3 groups: standard care vs brief intervention (40-60 minutes) vs
brief intervention with booster 7-10 days after initial BI (BIB)
• 1 year f/u = 84%
• All 3 groups reduced days of heavy drinking• BIB subjects had fewer DrInC consequences (2.24 vs 2.4 (BI) and
2.52 (SC))• BIB had fewer alcohol-related injuries than SC (0.456 vs 0.165) The
average at baseline for whole sample 1.6
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Components of the BNI
STEP 1: Raise the Subject
STEP 2: Provide Feedback
STEP 3: Enhance Motivation
STEP 4: Negotiate and Advise
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Step 1: Raise the Subject
• Establish Rapport
• Raise the subject of alcohol use
“Hello, I am….... Would you mind taking a few minutes to talk with me about your alcohol use?”
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Step 2: Provide Feedback
• Review patient’s drinking patterns
“From what I understand you are drinking…”
• Make connection to ED visit if possible
“What connection (if any) do you see between your drinking and this ED visit?”
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Step 2: Provide Feedback (Cont.)
• Compare to National Norms and offer NIAAA guidelines
“These are what we consider to be the upper limits of low-risk drinking for your age and sex. By low-risk we mean that you would be less likely to experience illness or injury.”
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Step 3: Enhance Motivation
• Assess readiness to change
“On a scale of 1-10 (1 being not ready and
10 being very ready) how ready are you to change any aspect your drinking?”
0 1 2 3 4 5 6 7 8 9 10
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Step 3: Enhance Motivation (cont)
• Develop discrepancy– Identify areas to discuss– Explore pros and cons if low readiness #– Use reflective listening
If patient indicates:> 2 : “Why did you choose that number and not a lower one? What are some reasons why you are thinking about changing?”
< 1: “Have you ever done anything that you wish you hadn’t while drinking? What would make this a
problem for you?”
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Step 4: Negotiate and Advise
• Elicit response “How does all this sound to you?”
• Negotiate a goal“What would you like to do?”
• Give advice“It is never safe to drink and drive, etc…”
• Summarize“This is what I heard you say… Thank you… (Provide PCP f/u or treatment referral)
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Models for SBIRT in the ED
• Project ED Heath:
Emergency Practitioners
Harmful and Hazardous Drinkers
• Project ASSERT:
Health Promotion Advocates
Alcohol and Other Drug Misuse and Dependence
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Emergency Practitioner Brief Intervention for Harmful and Hazardous Drinkers
PROJECT ED HEALTH
Gail D’Onofrio MD, Linda Degutis DrPH, David Fiellin MD, Michael Pantalon PhD,
Susan Busch PhD, Marek Chawarski PhD, Patrick O’Connor MD
(NIAAA 1 R01 AA12417)
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Project ED Health
• Funded by NIAAA
RO1 AA12417-01A1
• Collaborative initiative
Emergency Medicine
Medicine
Psychiatry
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Project ED Health: Primary Aims
• To develop, implement and test an EP-performed brief intervention for harmful and hazardous drinkers
• To determine the efficacy of these brief interventions on reducing alcohol consumption and negative consequences
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Hazardous/harmful drinking
• Hazardous drinking – Exceed NIAAA guidelines
• Male, > 14 drinks per week, > 4 drinks per occasion• Female, > 7 drinks per week, > 3 drinks per occasion• >65, > 7 drinks per week, > 3 drinks per occasion
• Harmful drinking– Injury with blood alcohol concentration > 0.2gm/dl
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Patients
• ED patients were screened using the NIAAA quantity/frequency questions embedded in an 18-item health quiz– Inclusion
• >18 years old• Harmful/hazardous drinking
– Exclusion• alcohol dependence (AUDIT scores >19)• cognitive impairment• critical illness• drug dependence
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Study Design
• Prospective Observational Study– EP (EM faculty, residents and physician
associate) education
• Randomized clinical trial– Brief Negotiation Interview (BNI) vs.
Discharge Instructions
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Training
• Emergency Practitioners (EPs) – MD faculty, 3rd and 4th year residents and Physician
Associates were trained to perform BNI
• 2-hour teaching sessions conducted by PI and Co-investigators consisted of:– 30 min didactic presentation– 10 min role play demonstration– 50 min case-based workshop – 30 min debriefing and (Q &A)
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BNI Trained 58 EPS
Results: EP Training and Proficiency
Not trained 2 EPs
1-fellow1-sabbatical
Remediated& Passed
3 (5%)
3-PAs
Passed 53 (91%)
NoRemediation
2 (4%)Left institution
1-faculty1-resident
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BNI Performance
• 47 of 58 EPs performed BNIs– Mean # BNIs performed per EP
• 5.28 ( + 4.91; range 0-28)
– Mean duration of BNI • 7.75 minutes ( + 3.18; range 4-24)
• 241 exit interviews with EPs– 237/241, EPs reported no problems with BNI– 4/241, EPs reported BNI interrupted due to
consultations or diagnostic testing
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Conclusions: Project ED Health
• A BNI for Harmful and Hazardous drinkers can be successfully developed for Emergency Practitioners.
• Emergency Practitioners can demonstrate proficiency in performing the BNI in routine ED clinical practice
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Project ED Health
Results of RCT
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Counseling Interventions
• Brief Negotiation Interview (BNI)– Provided by Emergency Practitioners (MD, PA) – Less than 10 minutes– Manual-guided script
• 1) Raise the subject of alcohol consumption• 2) Provide feedback on the patient’s drinking levels and effects• 3) Enhance motivation to reduce drinking• 4) Negotiate and advise a plan of action
• Discharge Instructions (DI)– Advice to decrease drinking embedded in a sheet providing
advice on general health (e.g. smoking cessation, exercise, seat-belt use)
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Counseling Competency
• All EPs evaluated using standardized patient– audio-taped to ensure adherence to and competence
with BNI– Rater evaluated whether critical actions were
completed
• Failure resulted in additional instruction and
retesting
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Data Collection
• Research assessments completed at baseline in the ED and at 1, 6 and 12 months by phone
• Alcohol consumption– Time-line follow back
• Negative consequences– Self-report of:
• Injury• Motor Vehicle Crashes• Driving while intoxicated• Missed work
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Adherence and Fidelity
• BNIs and DIs audio-taped ~ (90%)
• Rated for adherence to protocol
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Results
14,771Screened
571 Eligible
500 Randomized
250 BNI
250 DI
71 Not Randomized
67 refused4 missed
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Demographics
• Male: 68%
• Mean age 35.3; SD+15.9
• Race: 385 (77%) White, 104 (21%) Black
• ED visit prompted by injury: 34%
• ~30% had AUDIT scores < 8
• No difference by sex, age, race, or injury presentation
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Drinks per week
BNI
DI
P
Baseline 13.5 12.6 NS
1 month 8.5 9.6 NS
6 months 9.5 9.3 NS
12 months 9.9 10.0 NS
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Binge drinking(% binging in past 30 days)
BNI
DI
P
Baseline 92% 89% NS
1 month 55% 53% NS
6 months 54% 54% NS
12 months 52% 51% NS
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Drinks per week(by AUDIT score and condition)
0
5
10
15
20
25
30
Baseline 1 month 6 months 12 months
Ave
rag
e n
um
ber
of
dri
nks
per
wee
k
AUDIT <8 BNI AUDIT <8 DI AUDIT 8-15 BNI AUDIT 8-15 DI AUDIT >15 BNI AUDIT >15 DI
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Drinks per week(by gender and condition)
0
2
4
6
8
10
12
14
16
18
Baseline 1 month 6 months 12 months
Ave
rag
e n
um
ber
of
dri
nks
per
wee
k
Males BNI Males DI Females BNI Females DI
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Negative consequences(Injuries while drinking)
BNI
DI
P
Baseline 18 12 NS
12 months 8 10 <.03
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Negative consequences(Women, drinking while driving)
BNI
DI
P
Baseline 24 2 NS
12 months 15 19 <.05
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Adherence & Competence
• A Brief Intervention Adherence/Competence Scale • Independent tape rater training• Use of the scale to:
– discriminate between BNI & DI– assess the degree to which each Rx was
administered as intended– evaluate the association between
adherence/competence and drinking outcomes (on-going)
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BI Adherence/Competence Scale
Did the ED Provider (EP)…(YES, NO)
1) Ask patient for permission to discuss alcohol use & pause for answer?
2) Review patient’s drinking patterns and express concern?
3) Ask patient if he/she sees a connection between drinking & ED visit?
4) Make a specific connection between drinking and ED visit or other medical issue (e.g., MVC, GI complaints, hypertension)?
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5) Inform pt re: NIAAA guidelines relevant to his/her sex and age group and tell patient his/her drinking is above guidelines and unsafe?
6) Ask patient to select a number on the “Readiness Ruler”?
7) What was the number?
8) Ask patient why he/she did not pick a lower number?
BI Adherence/Competence Scale
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BI Adherence/Competence Scale
9) Ask Patient: What would make his/her drinking a problem? OR Ask how important would it be for the patient to prevent that from happening? OR Discuss
patient’s pros and cons of drinking?
10) Tell patient in a confrontational manner, that they have to cut down?
11) Make suggestions regarding how much patient should cut down?
12) Refer to patient as an “alcoholic”
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BI Adherence/Competence Scale
13) Negotiate a drinking goal with the patient based on what patient has said by asking: What would you like to do?
14) Tell patient that if he/she can stay within NIAAA limits he/she will be less likely to experience (further) illness
or injury related to alcohol use?
15) Provide a drinking agreement sheet?
16) Add his/her advice on the agreement?
17) Provide “Project ED Health” Information sheet?
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BI Adherence/Competence Scale
18) Encourage patient to follow-up with his/her PCP?
19) Thank patient for his/her time?
20) Offer confrontational warnings regarding drinking?
21) To what degree does the provider reflect patient’s motivational statements regarding cutting down? (1-7)
22) Re-direct non-motivational statements? (1-7)
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Independent Tape Rater Training
• 4 Raters trained– 4 hours of didactics & tape rating practice PLUS a 1-
hour booster– 5 training tapes rated by each rater (>85% agreement)
• Inter-rater reliability– 20 tapes given to remaining 3 raters– 15 tapes were rated– Mean agreement across all items=82%– >80% agreement on all items except for:
• Made suggestions re: how much to cut down (33.3% agreement)• Negotiated drinking goal (73.3% agreement)• Informed pt that staying within limits lowers risk (33.3 agreement )• Added advice to drinking agreement (53.3% agreement)
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Discriminating between BNI & DI sessions (N=367)
• Session Length– Mean BNI min. > Mean DI min. (6.73 vs. 1.38, p<.01)
• Adherence/Competence ScoreTreatment Group BNI* DI
BNI 8.9 0.69 DI 0.5 0.88
*BNI scores range is from -3 to 13, which excludes DI-prescribed items; BNI sessions’ BNI score > DI, p<.01
• Item analyses revealed significantly greater use of BNI components in BNI vs. DI group on all items (p<.01), except
for info sheet item (DI>BNI) and proscribed items, where frequency low & comparable between the 2 groups.• BNI > DI on Reflective listening scores, but very little was actually
done (2.20/7 vs. 1/7, p<.01).
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To what degree did EPs administer BNI as intended?
• BNI Passing Score of 12/15 (80%) achieved in 42% of BNI sessions (X=10.3/15 or 69%)
• Contrary to the manual, however, 8% of BNI sessions included some “confrontational warnings regarding drinking”
• Additionally, the BNI components most frequently & mistakenly omitted were…– Inform pts of benefits of staying within limits (47.3%)– Providing pts with info sheet (30.8%)
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To what degree did EPs administer DI as intended?
• DI Passing Score of 1 (i.e., info sheet provided without any use of BNI components) achieved in 64.3% of DI sessions
• However, 33% of DI sessions included at >1 BNI components… – 21.2% “asked permission to talk about alcohol”– 6% “made a specific connection between drinking &
ED visit…” and/or used word “alcoholic”– 3% “reviewed drinking patterns & expressed
concern...” or “offered confrontational warnings”• Additionally, the 1 critical DI component (i.e., giving info
sheet) was mistakenly omitted in 6% of DI sessions.
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Adherence & Competence Conclusions
• BNI & DI are discriminable• Both treatments were administered with fair-to-good adherence
and competence during the trial• However, some prescribed components were missed (benefits
of change and directive advice-giving in the BNI group & info sheet in DI) and some proscribed components were included in both treatments (confrontation, use of “alcoholic”).
• This may have lessened the overall contrast between the 2 treatment conditions and may have contributed to the “no difference” finding.
• These findings and on-going analyses on the association between the various BNI components and drinking outcomes will shape our understanding of the BI techniques most critical to promoting change in harmful and hazardous drinkers in the ED.
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Summary
• BNI and DI are associated with decreased alcohol consumption in harmful/hazardous drinking in the ED
• BNI is associated with decreased negative consequences including injury, and drinking and driving in females
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Conclusion
• BNI is teachable and acceptable to EPs
• BNI is feasible to perform in ED setting in the context of routine clinical care
• Unable to demonstrate significant difference between BNI and DI with respect to alcohol consumption
• Strategies to augment BNI need to be evaluated
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Project ASSERT
• Funded by:– Robert Wood Johnson Foundation,
New Haven Fighting Back Initiative– CT Department of Mental Health and
Addiction Services– Section of Emergency Medicine, Yale
University School of Medicine
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Health Promotion Advocates (HPAs)
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Project ASSERT
• Background– Community outreach workers who identify and
provide early intervention for ED patients with alcohol and other drug problems & other selected health risks such as domestic violence, smoking, depression, and access to primary care
• Model – Implementation: HPAs 2.6 FTE– Participants: > 18 years-old– Survey: 10 min face-to-face
interview– Intervention: Brief Intervention, referrals– Follow-up: Phone \ facility contact
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Screening
• In 5 years the Project ASSERT team has successfully screened over 18,000 patients
White44%
Black28%
Hispanic25%
Other3%
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Alcohol Consumption
n %
Alcohol Consumption 10,075 42.3 (23,727)
Exceeds NIAAA Criteria
9,720 96.3
At Risk/Hazardous (Exceeds NIAAA, CAGE <1)
5,776 57.2
Dependence (Exceeds NIAAA, CAGE >2)
3,944 39.1
Binge Drinking 1,551 15.4
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Other Drug Use
• 15% of all patients use illicit drugs
• Most common drugs used are:– cocaine/crack(59%)– heroin (38%)– marijuana(36%)
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Referrals to Specialized Treatment Centers
Other Drugs
23%
Alcohol andOther Drugs 12%
Referrals 3,249
Alcohol
65%
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Treatment Enrollment
Enrolled89%
Not Enrolled
11%
Percentages were calculated from patients that were contacted 2,416 (74.4% of total referred), divided by patients who enrolled 2113 (87.5%).
Enrolled
87.5%
Not Enrolled 12.5%
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Conclusions: Project ASSERT
• The Project ASSERT model can– be successfully integrated into the real world
ED setting – directly link patients to specialized treatment
programs
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Summary
• SBI is a skill that can be learned by Emergency Practitioners and peer educators
• Health Promotion Advocates can successfully link ED patients with specialized treatment programs
• System to drive SBI must be developed
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Strategies to Drive Change
• Overcome Clinical Inertia – Recognition of the problem, but failure to act.
(Phillips LS Ann Intern Med 2001;135:825-34)
• Provide skills-based workshops
• Elicit opinion leaders
• Institute system changes
• Provide ongoing feedback & incentives
• Be creative
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The Diffusion of Innovations to Prevent Disease, Disability and Death: An Historical Perspective
• Brief interventions: 300 yrs• SSOT screening: 175+ years• Scurvy: 50 years• SBIR: 25 years
Thomas F. Babor