Transcript Brief Intervention and Referral to Treatment EMERGENCY MEDICINE Morbidity and Mortality  >107,000 alcohol related deaths each year  1/3 of adult hospital admissions are alcohol.

Brief Intervention and
Referral to Treatment
EMERGENCY MEDICINE
Morbidity and Mortality
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>107,000 alcohol related deaths each year
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1/3 of adult hospital admissions are alcohol related
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Attributable risk factor for multiple illnesses
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Major risk factor for all categories of injury
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Problem drinkers have 2x injury events/yr and 4x as many
hospitalizations for injury
A single alcohol-related visit predicts continued problem
drinking
Social and family issues
Alcohol Related Injuries
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150,000 injury deaths in U.S. each year
several hundred thousand disabling
injuries per year
15-34 years olds at highest risk
alcohol use involved in large proportion of
deaths and injuries
Alcohol Related
Costs
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Medical treatment, insurance,
unemployment, lack of productivity
Families with an alcoholic member have
twice the average monthly health care bill
than other families
Alcohol Related Casualties
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Under reported on death certificates
Under reported on hospital discharge
Selection and recording bias
Alcohol-Related Fatalities in MVCs
27,500
25,000
22,500
20,000
17,500
15,000
12,500
10,000
7,500
5,000
2,500
0
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
.16 = Median and Mode BAC
Number of Drivers
800
700
600
500
400
300
200
100
0
0
.05 .10 .15 .20 .25 .30 .35 .40 .45+
BAC -- 2002
Source: 2002 ARF FARS
Drinking Patterns in the U. S.
Abstain 40%
Dependent 5%
At Risk or Problem
20%
Low Risk 35%
Source: National Longitudinal Alcohol Epidemiologic Survey, 1992
Prevention and Intervention
ABSTAINERS &
MILD DRINKERS
(70%)
MODERATE
(20%)
at risk drinkers
SEVERE
(10%)
Specialized Treatment
Brief Intervention
Primary Prevention
Alcohol Terminology
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Hazardous drinking - at-risk drinking
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Harmful drinking
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NIAAA definition
Health consequences
Binge drinking
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5 or more drinks per drinking episode
Alcohol Terminology
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Dependence - cluster of symptoms
including impaired control over intake,
withdrawal symptoms, tolerance, drinking
despite problems
Abuse - repetitive patterns of drinking in
harmful situations with adverse
consequences, including impaired ability
to fulfill responsibilities or negative effects
on social/interpersonal functioning and
health
Issues related to lack of
exploration of alcohol use
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Lack of understanding of problem
Failure to acknowledge responsibility for
identification/intervention
Biases - personal/professional
Feeling that nothing can be done
Not knowing what can be done
Outside of what is thought to be the
traditional realm of medical care providers
Issues Related to ED Provider
Screening for Alcohol Use
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Alcohol screening not traditionally
part of physician job
Not comfortable with alcohol
related issues
Don’t know how to intervene
Frustration over prior experiences
with patients who abuse alcohol
Alcohol Use as Part of the
Medical History
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Alcohol use
Quantity
Frequency
Type of alcohol used
Problems related to alcohol use
Alcohol Screening - Issues
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Not seen as responsibility of physician in
ED
Included as part of “social” history
Providers not educated concerning
importance of alcohol screening as routine
practice
Providers not educated concerning how to
ask the questions
Alcohol Interventions
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Brief intervention
Further evaluation and more
extensive intervention for person
with more significant problem
Provider intervention may be more
effective
Social Morays
A Standard Drink
A standard drink is 12 grams of pure alcohol or:
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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”:
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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
Brief Intervention
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Short counseling sessions (5-45 minutes)
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Single or repeated sessions
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Performed by non-addiction specialists
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Contain advice and/or motivational
enhancement
Brief Intervention
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At risk/problem drinkers
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Advise to cut down
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Set goals
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Provide Primary Care follow-up
Dependence
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Advise to abstain
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Refer to treatment
Advise: What?
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ABSTAIN
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pregnant or
considering
medication that
interacts
dependence
failed attempts to cut
down
contraindicated
medical condition
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CUT DOWN
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drinking above low
risk amounts
no dependence
no problems
Stages of Change Model
Pre-Contemplation
Contemplation
Preparation
Maintenance
Action
Prochaska & DiClemente, 1986
General Principles for
Negotiating Behavior Change
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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