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Screening and Brief Intervention in the Emergency Department

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Screening and Brief Intervention in the Emergency Department Screening and Brief Intervention in the Emergency Department Gail D’Onofrio, M.D., M.S., and Linda C. Degutis, Dr.P.H. Many patients visiting hospital emergency departments (EDs) or admitted to trauma centers have alcohol problems. Therefore, it is plausible that all ED and trauma patients should be screened for unhealthy alcohol use so that optimal care can be provided and treatment initiated, if necessary, for these patients. In addition, brief interventions offered directly in the ED or trauma unit could be useful for many patients. Some studies have found such interventions to be feasible and effective in this setting. However, all efforts in this regard must take into consideration the specific challenges associated with screening and intervention in EDs, such as time constraints, ethical and legal issues, and concerns regarding insurance coverage. Innovative approaches to screening may address at least some of these problems, although more research is needed to determine how screening can be better incorporated and implemented in the ED setting. KEY WORDS: hazardous AOD (alcohol and other drug) use; harmful AOD use; alcohol abuse; emergency room; trauma center; drinking and driving; identification and screening; intervention (persuasion to treatment); brief intervention; counseling; motivational interviewing; barriers to treatment; literature review any patients visiting hospital ing and brief interventions in this setting, (D’Onofrio and Degutis 2002). In emergency departments including ethical and legal barriers to addition, patients treated in EDs are M(EDs) exhibit unhealthy screening and intervention. In addition, 1.5 to 3 times more likely than those alcohol use (Saitz 2005), which encom- innovative approaches to screening and passes patterns of alcohol consumption intervention in the ED are presented, GAIL D’ONOFRIO, M.D., M.S., is an that put the drinker at risk for adverse and issues that need to be addressed in associate professor in the Department of consequences (known as at-risk drinking), future studies are discussed. Surgery, Section of Emergency Medicine, have led to alcohol-related problems but and interim chief of the Section of do not meet the criteria for an alcohol Emergency Medicine, Yale University School use disorder (known as problem drink- Prevalence of Unhealthy of Medicine, New Haven, Connecticut. ing), or meet the criteria for an alcohol Alcohol Use in ED Patients use disorder (i.e., alcohol abuse or alcohol LINDA C. DEGUTIS, DR.P.H., is an dependence). (For more information, A substantial portion of the estimated associate professor in the Department of see the textbox.) As a result, ED practi- 110 million ED visits in the United Surgery, Section of Emergency Medicine, tioners routinely care for patients with States each year are related to unhealthy and research director of the Section of adverse health effects associated with alcohol use. As many as 24 to 31 percent Emergency Medicine, Yale University alcohol consumption. This article exam- of all patients who are treated in an ED School of Medicine, New Haven, ines the prevalence of alcohol-related and as many as 50 percent of severely Connecticut. health problems among ED patients, injured trauma patients (i.e., patients reviews studies evaluating the effective- who require hospital admission, usually Funding support for the preparation of ness and feasibility of brief interventions to an intensive care unit, for treatment this article was provided by National in the ED setting, and points out partic- of acute injuries) have positive results Institute on Alcohol Abuse and Alcoholism ular challenges associated with screen- when screened for alcohol problems grant R01–AA–12417. Vol. 28, No. 2, 2004/2005 63 treated at primary care clinics to report heavy drinking, adverse consequences Definitions of Unhealthy Alcohol Use of drinking (e.g., alcohol-related injuries, illnesses, and legal or social problems), The term “unhealthy alcohol use” refers to a spectrum of disorders ranging or having ever been treated for an alco­ from at-risk drinking to alcohol dependence. At-risk or hazardous drinking hol problem (Cherpitel 1999). implies that the person is drinking over the recommended limits and is The prevalence of alcohol use disor­ therefore vulnerable to illness, injury, or social/legal problems. These recom­ ders in ED patients was confirmed by a mended consumption limits are, for men, 2 standard drinks per drinking study conducted in seven representative occasion or 14 standard drinks per week, and, for women and people age EDs across Tennessee, in which patients 65 and over, 1 standard drink per drinking occasion or 7 drinks per week. were assessed to determine their need A standard drink is defined as 12 grams of pure alcohol, the amount con­ for alcohol and other drug (AOD) tained in approximately 12 oz of beer, 5 oz of wine, or 1.5 oz of distilled treatment (Rockett et al. 2003). The spirits. researchers reported that, based on the Once a person experiences an alcohol-related harmful event—an injury, assessment, as many as 27 percent of illness, or social/legal problem such as poor grades, an argument with parents, ED patients needed AOD treatment or a driving violation—he or she is classified as a harmful drinker. services; however, in only 1 percent of The far end of the spectrum includes alcohol abuse and alcohol depen­ the cases did the ED physicians docu­ dence as defined by the diagnostic criteria that have been established in the ment a diagnosis of AOD abuse in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental patients’ medical files. Moreover, less Disorders, Fourth Edition (DSM–IV). than 10 percent of the patients deter­ mined to be in need of AOD treatment actually received any. Patients were more on Drug Abuse (SAMHSA 2003b), 3 entire spectrum of unhealthy alcohol likely to need AOD treatment services million people ages 16 to 20 had driven use and that they be offered brief inter­ if they were insured by Medicaid or under the influence of alcohol at least vention and referral to treatment services. Medicare, had come to the ED 2 or more once in the past year, including 600,000 hours after the onset of the illness or people ages 16 or 17. Motor vehicle injury (i.e., had delayed the ED visit), crashes are the number one cause of Effectiveness of Brief or had visited the ED more than once. death in people ages 1 to 35, and the Interventions in the Interestingly, no difference in treatment eighth leading cause of death overall ED Setting need existed between patients visiting (CDC 2004). In 2003 (the most recent the ED because of an injury (e.g., from data available), there were approximately ED practitioners are chronically pressed an alcohol-related car crash or fall) and 43,000 motor vehicle traffic fatalities for time, and resources often are limited patients visiting the ED for other illnesses. in the United States, according to the in this setting. Therefore, if ED practi­ Finally, treatment need was inversely National Highway and Traffic Safety tioners are to be encouraged to screen associated with age—that is, younger Administration (NHTSA), of which their patients for alcohol problems and patients were more likely to need AOD an estimated 18,000 (40 percent) were offer brief intervention if necessary, treatment than older patients. related to the use or abuse of alcohol particularly under the time constraints Several factors contribute to the fact (NHTSA 2005). Consequently, NHTSA they are facing, they first must be that younger ED patients may be more has made prevention of impaired driv­ convinced of the usefulness of these likely to have alcohol-related problems ing a major initiative and is working measures. Brief interventions are short that indicate a need for treatment. First, to encourage health care practitioners counseling sessions, ranging from 5 to younger people are usually healthy and (including those in EDs) to provide 60 minutes, performed by nonaddic­ are more likely than older people to be screening and brief intervention services. tion specialists. Including the concepts uninsured and to use the ED as their This initiative supports the Institute of motivational interviewing (MI) may usual source of care (McCarthy et al. of Medicine’s (1990) landmark report enhance the success of the intervention 2002).1 Second, young adults have the on broadening the base of AOD abuse in changing patients’ behavior. The highest prevalence of binge2 and haz­ treatment, which recommends that principles of MI, developed by Miller ardous drinking in the United States patients in all medical settings should and Rollnick (1991), are encapsulated (SAMHSA 2003a), which can easily be screened for problems along the in the FRAMES acronym (feedback, escalate to drinking patterns that require responsibility, advice, menu or choice, 1The various studies define “older” and “younger” differ­ intervention. ently. Most commonly, “younger people” are those age 25 empathy, and self-efficacy). The goal Third, particularly in younger people, and younger. of the brief intervention is to assist these drinking patterns often occur in patients who exhibit less severe patterns 2Binge drinking as it is used here is defined as consump­ conjunction with driving. According to tion of five or more drinks on one drinking occasion; it also of unhealthy alcohol use (i.e., at-risk the 2001 National Household Survey is called heavy episodic drinking. drinking and problem drinking) to 64 Alcohol Research & Health Screening and BI in the Emergency Department reduce their alcohol consumption to teens in an urgent care setting” and Participants were randomly assigned to low-risk levels, thereby reducing the risk included a handout on avoiding drink­ one of three groups: of illness or injury. For those patients ing and driving as well as a list of local who are alcohol dependent, the goal treatment agencies.
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