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

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

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

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

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

Top 10 Leading Causes of Death in the United States for 2001, by Age Group

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

BAC Levels for Alcohol Positive Drivers Involved in Alcohol-Related Fatal Crashes

Source: 2002 ARF FARS

.16 = Median and Mode BAC

Drinking Patterns in the U. S.

Dependent 5%

At Risk or Problem20%

Source: National Longitudinal Alcohol Epidemiologic Survey, 1992

Low Risk 35%

Abstain 40%

Universal Screening Widens The Net

ABSTAINERS & MILD DRINKERS

(70%)

MODERATE(20%)

at risk drinkers

SEVERE (10%)

Primary Prevention

Brief Intervention

Specialized Treatment

Social Morays

Stereotypic “Alcoholic”

Role of the Practitioner

• Identify

• Assess

• Brief intervention

• Refer

Screening

• Diagnostic tests

– Blood alcohol concentration (BAC)

– Saliva alcohol test

– Breathalyzer

– Adjunct tests (abnormal liver function tests,

macrocytic anemia)

Screening

• Structured questionnaires– CAGE– TWEAK– AUDIT– Brief MAST– CRAFFT

• Quantity & frequency questions (NIAAA)

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

ASK about Alcohol Use

• Consumption

• CAGE

Per week

Per occasion

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?

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

Screen Positive

Drinks per

week

Drinks per occasion

Men > 14 > 4

Women > 7 > 3

All Age >65 > 7 > 1

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

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

ASK Current Drinkers

CAGE

C Cut DownA AnnoyedG GuiltyE Eye Opener

Assessment: Level of Severity

• At risk

No current problems

• Experiencing problems

Medical

Behavioral

• Signs of dependence

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’?

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.

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?

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?

Brief Intervention

• Short counseling sessions (5-45 minutes)

• Single or repeated sessions

• Performed by non-addiction specialists

• Contain advice and/or motivational

enhancement

Brief Intervention

• At risk/problem drinkers– Advise to cut down

– Set goals

– Provide Primary Care follow-up

• Dependence– Advise to abstain

– Refer to treatment

Stages of Change Model

Pre-Contemplation Contemplation

Maintenance

Action

Preparation

Prochaska & DiClemente, 1986

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

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)

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

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

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

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

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

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

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)

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)

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

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

Components of the BNI

STEP 1: Raise the Subject

STEP 2: Provide Feedback

STEP 3: Enhance Motivation

STEP 4: Negotiate and Advise

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?”

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?”

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.”

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

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?”

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)

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

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)

Project ED Health

• Funded by NIAAA

RO1 AA12417-01A1

• Collaborative initiative

Emergency Medicine

Medicine

Psychiatry

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

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

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

Study Design

• Prospective Observational Study– EP (EM faculty, residents and physician

associate) education

• Randomized clinical trial– Brief Negotiation Interview (BNI) vs.

Discharge Instructions

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)

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

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

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

Project ED Health

Results of RCT

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)

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

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

Adherence and Fidelity

• BNIs and DIs audio-taped ~ (90%)

• Rated for adherence to protocol

Results

14,771Screened

571 Eligible

500 Randomized

250 BNI

250 DI

71 Not Randomized

67 refused4 missed

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

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

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

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

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

Negative consequences(Injuries while drinking)

BNI

DI

P

Baseline 18 12 NS

12 months 8 10 <.03

Negative consequences(Women, drinking while driving)

BNI

DI

P

Baseline 24 2 NS

12 months 15 19 <.05

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)

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)?

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

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”

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?

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)

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)

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).

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%)

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.

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.

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

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

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

Health Promotion Advocates (HPAs)

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

Screening

• In 5 years the Project ASSERT team has successfully screened over 18,000 patients

White44%

Black28%

Hispanic25%

Other3%

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

Other Drug Use

• 15% of all patients use illicit drugs

• Most common drugs used are:– cocaine/crack(59%)– heroin (38%)– marijuana(36%)

Referrals to Specialized Treatment Centers

Other Drugs

23%

Alcohol andOther Drugs 12%

Referrals 3,249

Alcohol

65%

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%

Conclusions: Project ASSERT

• The Project ASSERT model can– be successfully integrated into the real world

ED setting – directly link patients to specialized treatment

programs

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

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

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