1. Alcohol Screening and the Brief Negotiated Intervention (BNI). What is it & Does it Work?

2. 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 the SBI

3. Alcohol Screening in the ED Why should we care?

4. Why Do We Care?  Prevalence  Morbidity & Mortality  Diminished Quality of Life  Harm to Self & Others

5. Alcohol Abuse Effects  $100 billion annual national cost  $27 billion is from lost productivity  111 million US regular alcohol users  34% of persons 19-28 years engage in binge drinking or drank heavily in past 30 days  Dept Health & Human Services, 8th congressional report, 1993 x

6. National Hospital Ambulatory Medical Care Survey 2001 Emergency Department Summary  107.5 million visits 38.4/100 persons  39.4 million injury visits 14.1/100 persons  4.1 hour mean alcohol visit duration  2.5 million (2.3%) documented alcohol related visits  11.4% referrals for alcohol treatment

7. Scope of the Problem  31% of adults presenting to and urban ED reported > to 2 CAGE positive (Bernstein 1996)  24% of adults presenting by ambulance to an urban ED reported > 2 CAGE positive (Whiteman 2000)  ED patients are 1.5-3.0 times more likely to report heavy drinking or consequences than those in Primary Care (Cherpitel 1999)

8. 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

9. Alcohol-Related Fatalities

10. Young Adults  17% of 8 th graders, 33% of 10th graders & 47% of 12th graders report alcohol use in the past month  11% of 8th graders, 21% of 10 th graders & 28% of 12th graders report binge drinking (5 drinks in a row) in the past two weeks Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey, 2005. www.monitoringthefuture.orgwww.monitoringthefuture.org

11. Young Adults  Highest prevalence of alcohol consumption  Major concern for college campuses  Drivers between the ages of 16-25 account for 30% of alcohol-related fatalities

12. Americans 18 and older  10 million (5%) dependent drinkers  40 million (20%) high risk drinkers  70 million (35%) moderate drinkers  80 million (40%) abstain National Longitudinal Alcohol Epidemiologic Survey, 1992

13. Elderly  10% of ED patients with alcohol problems are > 60 years of age  Increased sensitivity to alcohol effects  Associated with depression and suicide attempts  At risk for medication interactions

14. Ambulatory medical care survey Nation’s Public Health Agenda: Healthy People 2010  Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these problems in the emergency department

15. Why Early intervention?  Screening and referral increases treatment contact  $ saved  Improved prognosis  Medical opportunity is ‘Teachable Moment’

16. UNIVERSAL SCREENING WIDENS THE NET ABSTAINERS & MILD DRINKERS (70%) MODERATE (20%) at risk drinkers SEVERE (10%) Primary Prevention Brief Intervention Specialized Treatment

17. Importance of Detection  Davidson, et al noted that a single alcohol related ED visit is an important predictor of continued problem drinking, alcohol impaired driving, and, possibly, premature death Davidson et al. Ann Emerg Med. 1997

18. Detection and Referral Does it matter?????

19. Fleming “ 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 et al. JAMA 1997;277:1039-1047

20. 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

21. COST-BENEFIT ANALYSIS OF BRIEF MOTIVATION  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 Fleming MF, et al. Medical Care 2000; 38:7-18.

22. 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

23. Adolescents BNI Monti, et al “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)

24. Adolescents BNI Monti, et al 94 Randomized  87 completed 3 month, 84 (89%) completed 6 month Monti, et al. J of Consulting and Psychology. 1999;67:6.

25. Still engaging in this behavior Adolescents BNI Monti, et al

26. Longbaugh et al  386 patients entered  3 groups: Control, Intervention and Intervention with a booster session  The Brief intervention with booster showed the best results. Longbaugh. J of Studies on Alcohol. Nov 2001.

27. 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)

28. Gentilello Reduction most apparent in mild-mod 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

29. Ok, What is the Brief Negotiated Interview & How do I perform this technique?

30. Components of the BNI 1. Raise the Subject 2. Provide Feedback 3. Enhance Motivation 4. Negotiate and Advise

31. 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?”

32. Establish Rapport  To understand the patient’s concerns and circumstances  To explain the providers concern/role  To avoid a judgmental stance

33. Raise the subject  Get the patient’s agreement to talk about the alcohol or drug use  Talk about the pros and cons of their use/abuse  Re-state what they have said regarding the pros and cons

34. What if the patient does not want to talk about their use/abuse ? “ Okay, I see you aren’t ready to talk about this today. Remember that we are here 24 / 7 if you change your mind”

35. 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?

36. Screen Positive Drinks per week Drinks per occasion Men> 14 > 4 Women> 7> 3 All Age >65> 7> 3

37. Drinking Patterns % of US adults aged 18+ Abuse without dependence Dependence with or without abuse Exceeds daily limit < once a week 16%1 in 8 (12%) 1 in 20 (5%) Exceeds daily limit once a week or more 3%1 in 5 (19%) 1 in 8 (12%) Exceeds both weekly & daily limits 9%1 in 5 (19) 1 in 4 (28) Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003

38. ASK Current Drinkers CAGE C Cut Down A Annoyed G Guilty E Eye Opener

39. Step 2:Provide Feedback  Review patient’s drinking patterns  Make connection to ED visit if possible  Compare to National Norms and offer NIAAA guidelines

40. Step 2:Provide Feedback “From what I understand you are drinking…” “What connection (if any) do you see between your drinking and this ED visit?” “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.”

41. Express Empathy and Rapport  Attitude : Acceptance by provider  Technique: Skillful reflective listening  Basis of change: Patient ambivalence

42. 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 patterns?” 1 2 3 4 5 6 7 8 9 10

43. Step 3: Enhance Motivation “On a scale from 1-10, how ready are you to change any aspect of your drinking? If patient indicates: > 2 : “Why did you choose that number and not a lower one? What are some reasons that 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.” Discuss pros and cons

44. Not Ready for Change  Don’t –Use shame or blame –Preach –Label –Stereotype –Confront

45. Avoid Argumentation  Counter productive  Defending breeds defensiveness  Perceptions can be shifted  Labeling is unnecessary  Resistance is a signal to change strategies –Rolling with resistance

46. Not Ready for change  Do –Offer information, support and further contact –Present feedback and concerns, if permitted –Negotiate: “What would it take you to consider a change ?”

47. Unsure Patients  Don’t –Jump ahead –Give advice –Expect argument about change  Do –Explore pros & cons –“help me to understand what alcohol does for you” –“Are there things you don’t like about your alcohol use?”

48. 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)

49. Develop Discrepancy Explore Pros and Cons  Patient awareness of situation  Discrepancy between present behavior and important goals as change motivator  Let the patient name the problem and the pros and cons

50. Dangerous Assumptions  This person ought to change  This person is ready to change  This person’s health is the prime motivating factor for them  If they decide not to change the BNI has failed

51. Dangerous Assumptions  Patients are either motivated or not  Now is the right time to change  A tough approach is best  I am the expert and they should follow my advice

52. The Ready Patient  Help the patient to: –Name a solution for themselves –Choose a course of action –Decide how to achieve it –Encourage patient choice

53. Referral  Consult the – Social worker –Psychiatric services  Discharge sheet of possible centers and / or programs and information

54. Summary  Alcohol problems are common, identifiable and treatable disorders  Knowledge and skills for screening and intervention can be learned

55. Remember: Just start the conversation, you may save a life!