Emergency Department Screening and Intervention for Patients with Alcohol-Related Disorders: a Pilot Study

ORIGINAL CONTRIBUTION

Emergency Department Screening and Intervention for Patients With Alcohol-Related Disorders: A Pilot Study

Aaron Craig Love, DO; Marna Rayl Greenberg, DO; Matthew Brice, DO; and Michael Weinstock, MD

Context: Physicians in emergency departments (EDs) treat n estimated 40 million adults in the United States are con- more patients with alcohol-related disorders than do those in Asidered “heavy drinkers” of alcohol, with 10 million primary care settings. dependent on the substance, according to the National Insti- tute on Alcohol Abuse and Alcoholism (NIAAA).1 Misuse of Objectives: To implement an effective screening, brief inter- alcohol contributes to a wide range of harmful effects in vention, and referral (SBIR) program for use in EDs. Further, society. For example, the prevalence of alcohol abuse and to evaluate the impact of the program on alcohol-consump- dependency in individuals involved in motor vehicle acci- tion levels. dents is estimated to be 23%.1 In addition, there are Methods: A prospective cohort pilot study was conducted at 66.9 alcohol-related diagnoses per 10,000 adults annually in a suburban community teaching hospital using a convenience the United States.1 The economic costs of alcohol abuse were sample of ED patients and an original seven-question estimated at $184.6 billion annually in 1998.2 screening tool based on well-known guidelines. Subjects Based on probability sample comparisons of noninjured screening positive for possible alcohol abuse were given treat- patients seen in emergency departments (EDs) versus nonin- ment referrals. Follow-up telephone interviews were con- jured patients in primary care settings, it was found that physi- ducted 6 months later. cians in EDs treat a larger percentage of patients who misuse alcohol.3 Thus, there exists great potential for physicians in Results: Of the 1556 enrolled subjects, 251 (16%) were clas- EDs to have a beneficial impact on intervention efforts. sified as at-risk drinkers. Seventy-nine at-risk subjects The US Centers for Disease Control and Prevention, the (32% [95% CI, 26%-37%]) screened positive on CAGE-based National Highway Traffic Safety Administration (NHTSA), questions (Cut down, Annoyed, Guilty, Eye opener). At and the American College of Emergency Physicians (ACEP) follow-up, 20 (25% [95% CI, 16%-35%]) were successfully have spearheaded a nationwide effort to incorporate patient contacted. Of these 20 subjects, 5 (25%) refused to partici- screening for alcohol misuse into a broad-based program of pate in follow-up screening. For the remaining 15 individuals, injury prevention.4 In addition, the ACEP has received an follow-up screening indicated that the mean (SD) number of NHTSA grant to develop an alcohol-screening and brief inter- drinks consumed per week decreased from 28 (14) on study vention tool to help ED physicians address alcohol-related enrollment to 10 (10) at 6-month follow-up (PϽ.001). Max- injuries.4 A randomized controlled trial by Crawford et al5 imum number of drinks per occasion decreased from 12 (8) found reduced alcohol-consumption levels and ED visits in at enrollment to 6 (7) on follow-up (P=.008). Subject scores on alcohol-misusing patients who were screened and referred to the CAGE-based questions decreased from pre- to post- follow-up care with alcohol-abuse treatment specialists. Nev- intervention, though not significantly, with an average of ertheless, there remain considerable barriers to establishing and 2.1 (1) affirmative answers on enrollment and 1.5 (1.4) at evaluating the effectiveness of alcohol-screening programs. follow-up (P=.108). Although there have been more than 30 studies revealing Conclusion: Implementation of an effective SBIR program the beneficial impact of brief intervention in various clinical set- for alcohol-related disorders can be accomplished in the ED. tings for patients with alcohol-related disorders, there have J Am Osteopath Assoc. 2008;108:12-20 been few studies on the effectiveness of brief intervention under conditions commonly encountered in an ED.6 The goals of the present pilot study were to develop a brief alcohol- From the Department of Emergency Medicine at Lehigh Valley Hospital in screening and referral program for this patient population, to Bethlehem, Pa. investigate the feasibility of telephone follow-up after inter- Address correspondence to Aaron Craig Love, DO, 7437 Beaver Valley Rd, vention, and to determine the 6-month self-reported change in Prescott Valley, AZ 86314-1412. E-mail: [email protected] patients’ alcohol-consumption levels and CAGE scores. The CAGE questionnaire is an internationally used assessment Submitted August 31, 2006; revision received October 30, 2006; accepted instrument for identifying people who misuse alcohol. The November 1, 2006.

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letters in the acronym represent the standard four questions disorders conducted the training session. Pocket reference used in the test7: cards were developed and distributed to ED staff. An incentive program offering retail gift cards was used to increase Ⅲ Have you felt you ought to Cut down on your drinking? staff participation. Local newspapers were contacted and Ⅲ Have you been Annoyed by people criticizing your encouraged to publish articles about the SBIR program, further drinking? contributing to staff interest and participation. Ⅲ Have you felt Guilty about your drinking? Staff determined which patients to screen, being encour- Ⅲ Have you had a drink first thing in the morning (ie, an Eye aged to perform screening on any patient who answered “yes” opener) to steady your nerves, get rid of a hangover, or get or “yes, socially” to the question, “Do you drink alcohol?” your day started? This question is part of the standard social history obtained at triage in the ED of our hospital. Subjects who answered with Methods either affirmative response to this question were screened— We conducted a prospective cohort pilot study using conve- regardless of whether their presenting complaints were related nience sampling in a screening, brief intervention, and to alcohol consumption. We adopted this strategy because referral (SBIR) program for alcohol-use disorders in noncritical other researchers have recommended similar screening for care patients seeking treatment in the ED at Lehigh Valley Hos- any ED patient who consumes alcohol.8,9 In addition, it has pital in Allentown, Pa. Patients’ reasons for seeking ED treatment been shown that self-reporting of recent drinking is not a good may or may not have been related to alcohol consumption. indicator of alcohol abuse in ED populations.10 Subject The present project was referred to the institutional review screening was conducted by ED staff, depending on the avail- board at Lehigh Valley Hospital. The board deemed the project able time and resources, workload, and staff motivation. to be exempt from full review because it was designated a quality- We developed our SBIR tool (Appendix) based on the improvement initiative. Because of the social nuances of alcohol NIAAA at-risk drinking guidelines (“at-risk drinking” defined abuse, there was considerable concern that requiring written con- as >14 drinks/wk or >4 drinks per occasion for men age sent from the patients would diminish participation. Therefore, р65 years; >7 drinks/wk or >3 drinks per occasion for women verbal consent was obtained from patients for ED screening and of all ages and men older than 65 years) and the CAGE ques- postintervention telephone follow-up. Verbal consent was logged tionnaire.7 One standard drink was defined as 142 mL (5 oz) for subjects who could be contacted for follow-up. of wine; 43 mL (1.5 oz), spirits; or 341 mL (12 oz), regular beer. The NIAAA at-risk drinking guidelines have previously been Study Participants and Setting shown to result in the best balance of sensitivity and specificity Patients were eligible for and included in the present pilot for screening patients with alcohol-related disorders.10,11 To study if they were cognitively alert, cooperative, medically increase the selectivity for subjects’ current drinking patterns, stable, at least 14 years of age, and presented with a condition we added the phrase, “Within the past year...” to the beginning that did not result in hospital admission. Subjects were enrolled of each of the four standard CAGE questions. During the in the study at the hospital’s ED during a 6-month period, study period, the SBIR tool was placed on each new ED patient from April 2004 to October 2004. Patients who were excluded record. from study participation were customarily cared for at the Subjects who answered “yes” or “yes, socially” to the discretion of physicians and nurses. Physicians, nurses, and question, “Do you drink alcohol?” were screened first with the physician assistants in the ED performed the initial patient three NIAAA at-risk questions evaluating current drinking screening for alcohol misuse. A research assistant conducted habits. Subjects who screened positive according to these the telephone follow-up of subjects 6 months after intervention. guidelines were then screened with the four-question CAGE- Lehigh Valley Hospital is a suburban community teaching based portion of our SBIR tool. A positive result on this section hospital with approximately 30,000 visits to its ED every year. of the SBIR was defined as one affirmative answer to any of the The hospital is part of a three-site, tertiary care network that four questions. The total length of this screening process can has a total ED patient volume of more than 100,000 individ- be less than 1 minute, though we did not evaluate screening uals per year. time in this pilot study. The questions used in the screening process have been validated previously with high sensitivity and Intervention specificity in EDs.10,11 Prior to the data-collection phase of the present pilot study, ED Subjects who screened positive in both portions of the hospital staff (eg, resident and attending physicians, physi- SBIR were given copies of the NIAAA recommendations for cian assistants, and triage and bedside nurses) were given a 1- safe drinking habits and a list of local treatment facilities and hour training session on the importance of screening patients Alcoholics Anonymous resources. Each of these subjects were for alcohol-related disorders and on the use of our original also given a motivational interview by his or her ED staff screening tool.7 A nationally renowned expert in alcohol-use member. In this interview, the subject was encouraged to

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pursue follow-up treatment with a primary care physician. Of the 1556 screened subjects, 251 (16% [95% CI, 14%-18%]) Each practitioner determined the length and nature of the were classified as at-risk drinkers based on their responses. Sev- motivational interview, but subjects were generally told that enty-nine (32% [95% CI, 26%-37%]) of these at-risk subjects also consuming large amounts of alcohol could be detrimental to screened positive in the CAGE-based questions. their health and that they should strongly consider seeking Of these 79 subjects, at 6-month follow-up, 27 (34% follow-up consultation about their drinking. In addition, each [95% CI, 24%-45%]) were entirely lost to follow-up, most com- subject’s readiness to change was determined by the screener monly because of an incorrect telephone number. Thirty-two based on the general concept of different stages of change: subjects (40% [95% CI, 30%-51%]) could not be reached by precontemplation, contemplation, preparation and action, or the research assistant after two telephone calls and were lost maintenance. Clinicians were asked to document interven- to follow-up through attrition. Twenty subjects (25% tion results on the back of each subject’s SBIR form for later ref- [95% CI, 16%-35%]) were successfully contacted by the research erence by the research assistant during follow-up. assistant within two telephone calls. Of the 20 subjects successfully contacted, 5 (25%) refused to participate in follow-up 6-Month Follow-Up screening. Approximately 6 months after ED intervention, a nonblinded Screening of the remaining 15 contacted individuals indi- research assistant conducted follow-up telephone interviews cated that the mean (SD) number of drinks they consumed per with those subjects who screened positive for any of the CAGE- week decreased from 28 (14) at baseline to 10 (10) at 6-month based questions. Subjects’ telephone numbers were obtained follow-up (PϽ.001). The maximum number of drinks con- through ED records. sumed by subjects per occasion deceased from 12 (8) at base- Subjects were then grouped by availability for follow-up: line to 6 (7) at follow-up (P=.008). (1) entirely lost to follow-up, (2) lost to follow-up through Mean (SD) subject scores on the CAGE-based questions attrition, and (3) successfully reached. decreased from pre- to postintervention. However, this Subjects in the first group consisted of individuals with dis- decrease was not statistically significant, with an average of connected or incorrect telephone numbers. 2.1 (1) “yes” answers in the ED and 1.5 (1.4) “yes” answers at Telephone contact information for subjects in the second follow-up (P=.108). group was valid, but the research assistant remained unable Figure 1 presents a flowchart overview of the enrollment, to contact these individuals after two telephone calls. These tele- intervention, and results of the present pilot study. Figure 2 dis- phone calls were separated by at least 1 week and both plays the results in bar-graph format. attempts resulted in either an unanswered line or a message left with another person. Limitations The third group was composed of subjects who the There are a number of limitations to the present study. The research assistant spoke to within two telephone calls. Con- study’s prospective cohort design does not allow us to deter- tacted subjects were asked the same series of questions on the mine whether the ED intervention was, by itself, the cause of SBIR tool. the reduced alcohol use observed in subjects at 6-month follow- up. Even without intervention, subjects may view a visit to the Primary Data Analysis ED alone as a sentinel event, leading to reduced alcohol con- The percentage of drinkers who were determined to be at- sumption. Similarly, spontaneous counseling by staff in non- risk based on their responses to the first three questions of SBIR ED visits may lead to reduced alcohol consumption. the SBIR tool and the percentage of at-risk drinkers who Future studies would optimally include a control group with screened positive on the CAGE-based questions were calcu- randomization. lated. Percentages of subjects in each follow-up availability Selection of subjects who were able to be contacted within category were also calculated. two telephone calls may have led to bias in favor of individ- Changes in subjects’ alcohol-consumption levels and uals who are more likely to have reduced their alcohol con- CAGE scores from pre- to postintervention were determined. sumption (ie, individuals who have reliable contact informa- Confidence intervals (CI) were calculated for each proportion tion may be more likely to reduce their problem drinking). of data, and paired t tests were computed for pre- and postin- Self-reporting by patients is not an objective measure- tervention continuous level data. A P value of less than .05 was ment. Nevertheless, it has previously been shown to have considered statistically significant. overall consistency.12 In the present study and in other alcohol- consumption studies,13-15 self-reporting is a routine method for Results studying patterns of substance use over time. The only objec- A total of 1556 subjects were enrolled and screened in the pre- tive measurements available for such purposes are breathalyzer sent pilot study, including 794 women (51%) and 762 men tests and measurements of blood-alcohol level, both of which (49%). The mean (SD) age of these subjects was 38 (11.3) years. have the limitation of providing only a single data point. More-

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Patients Approached: 1562

Patients Enrolled: 1556

SBIR Screen—NIAAA At-Risk: 25 (16% [95% CI, 14%-18%])

SBIR Screen—CAGE-Positive: 79 (32% [95% CI, 26%-37%])

Brief Intervention: • Printed Recommendations • Motivational Interview • Referral

6-Month Follow-Up— 6-Month Follow-Up— 6-Month Follow-Up— Impossible to Contact: Unable to Contact: Successfully Contacted: 27 (34% [95% CI, 24%-45%]) 32 (40% [95% CI, 30%-51%]) 20 (25% [95% CI, 16%-35%])

Follow-Up Screening: 15 (75%)

SBIR Screen— SBIR Screen— SBIR Screen— No. of Drinks/Wk (SD): Maximum No. of Drinks CAGE Score: PRE 28 (14) per Occasion: PRE 2.1 (1.0) POST 10 (10) PRE 12 (8) POST 1.5 (1.4) PϽ.001* POST 6 (7) P=.108 P=.008*

Figure 1. Flowchart overview of the enrollment, intervention, and results of the emergency-department screening, brief intervention, and referral (SBIR) program for patients with alcohol-related disorders developed by Aaron Craig Love, DO; Marna Rayl Greenberg, DO; Matthew Brice, DO; and Michael Weinstock, MD. Numbers and percentages of subjects, along with confidence intervals (CIs), are shown at different stages of the program. Final results, comparing pre- (PRE) with postintervention (POST), are shown as mean (SD).*P value is statistically significant. Abbreviations: CAGE, Cut down, Annoyed, Guilty, Eye opener; NIAAA, National Institute on Alcohol Abuse and Alcoholism.

over, it has previously been reported that using a set of closed tional interviews conducted by ED staff. A scripted motiva- questions addressing both recent and long-term recall of tional interview could assist in controlling for this possibility. drinking patterns would capture the most accurate record of This variability could also be corrected by using an alcohol- self-reported alcohol-consumption levels.16 The SBIR tool used abuse treatment specialist to perform each intervention in the in the present study accomplished this goal. same manner—a step that might have the added benefit of Although the SBIR tool and ED discharge instructions helping to improve patient follow-up. were the same for all study subjects, there could have been con- Achieving adequate patient follow-up has been chal- siderable variation in the duration and content of the motiva- lenging to previous researchers, though using an alcohol-treat-

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A B 30 3.0 P<.001*

25 2.5

P=.108

20 2.0

15 1.5

P=.008* Mean No. of Drinks

10 Mean No. of “Yes” Answers 1.0

5 0.5

0 0 Per Week Maximum CAGE Score Per Occasion Emergency Department Alcohol Use Baseline 6-Month Follow-Up

Figure 2. Mean change in (A) alcohol use and (B) CAGE-based (Cut down, Annoyed, Guilty, Eye opener) score between emergency-department visit and 6-month follow-up for subjects (n=15) with alcohol-related disorders. Error bars represent 95% confidence intervals around the means. *P value is statistically significant

ment specialist has been shown to be an effective measure for mented on the back of the original SBIR form, allowing our tele- ED alcohol-abuse intervention.17 Due to financial constraints, phone follow-up research assistant access to each subject’s employing a dedicated specialist was not feasible in the pre- previous SBIR results. sent pilot study. Moreover, our aim was to conduct an SBIR program with the resources available in most EDs. Therefore, Comment this limitation can also be viewed as a strength, making our The need for alcohol-abuse intervention has been well estab- intervention more applicable to most ED settings. lished.8 Ensuring the recognition of alcohol’s relation to disease Variation resulting from different practitioners may have and injury is of paramount importance in the ED, and an SBIR been reduced by the fact that intervention results were docu- program could help achieve this goal. The two main barriers

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that hinder the implementation of an SBIR program in EDs grams in that setting. The development and evaluation of already overwhelmed by existing workloads are efficacy and SBIR programs under actual ED conditions requires researchers time constraints for implementation. to create very time-efficient interventions and minimize the Findings in the present pilot study reveal that, among research burden on clinical staff. Patient tolerance is another heavy drinkers, the SBIR program resulted in significant reduc- important consideration. The intervention used in the present tions in alcohol consumption at 6-month follow-up, as mea- study was neither invasive nor time consuming. Therefore, sured in the number of drinks consumed per week (PϽ.001) and few subjects refused participation. In studies with more exten- maximum number of drinks consumed per occasion (P=.008). sive intervention, a greater rate of subject refusal can be These results are comparable to those described in a large meta- expected.18 analysis conducted by D’Onofrio and Degutis,6 who reported In establishing a SBIR program for the ED, we experi- reductions in alcohol consumption 3 to 6 months after brief enced both successes and barriers. Carrying out SBIR proce- intervention. However, the studies included in that meta-anal- dures can be a complicated and time-consuming task, especially ysis6 show that significant reductions were found when patients if study protocols are unclear to clinical staff. The following six with the most severe alcohol-consumption patterns were intervention elements, known by the acronym FRAMES, have excluded. Our results, by contrast, show decreased alcohol use been identified as successfully motivating patients to change in subjects with the highest consumption rates. their alcohol-consumption patterns19: It is difficult to ensure patient compliance with nontreat- ment follow-up appointments. Encouragingly, however, Craw- Ⅲ Feedback—Caregiver relates how alcohol can adversely ford et al5 found reduced alcohol-consumption patterns in affect patient health patients after brief intervention, regardless of whether they Ⅲ Responsibility—Caregiver emphasizes that only the patient kept follow-up appointments. Our pilot study was not can decide to improve his or her life designed to investigate whether patients kept their follow-up Ⅲ Advice—Caregiver helps patient set goals referrals. Instead, our objective was to investigate change in Ⅲ Menu—Caregiver provides alternate treatment options for alcohol-consumption patterns after an ED intervention and patient referral—perhaps the simplest variable we can affect in the ED. Ⅲ Empathy—Caregiver empathizes with patient’s difficulty in After a search of the National Library of Medicine’s talking about problem PubMed database using the keywords alcohol abuse, alcohol Ⅲ Self-efficacy—Caregiver stresses that patient can become intervention, and CAGE score for literature published since better with help 1980, we are aware of no prior study that has followed patients’ CAGE scores 6 months after an ED SBIR. Nor, to our knowl- Our SBIR program did not strictly adhere to these FRAMES ele- edge, has an SBIR program previously been validated as a ments. Nevertheless, we experienced successful outcomes by useful measure for alcohol-related disorders. The use of the incorporating SBIR into the standard elements that each ED SBIR program allowed us to ascertain subjects’ perceptions staff member at Lehigh Valley Hospital uses during patient about the potential harm of their alcohol-consumption pat- care. terns. Although these results did not reach statistical signifi- Some researchers have proposed that performing SBIR cance, a reduction in CAGE scores was seen. Bias in self- with a patient can take as little as 5 minutes.8 In addition, pre- reporting due to differences in subject willingness to change vious reviews have found little difference between the impact at follow-up versus baseline may have also contributed to of brief versus extended intervention.6 We reduced the time ele- reduced CAGE scores. In addition, there may have been a ment by leaving the extent of SBIR for each patient up to the Hawthorne effect resulting from the subjects’ awareness that judgment of the individual ED staff member, as well as by they were participating in a study—though the relative making the discharge-referral process as easy for these indi- anonymity of telephone follow-up should have made viduals as for other ED patients. answering “yes” to the CAGE-based questions easier. Our original SBIR tool has a total of seven questions. We The difficulties involved in follow-up are of utmost impor- believe that, though some sensitivity and specificity may be lost, tance in planning future investigations of alcohol-abuse inter- a screening questionnaire even shorter than the one used in the ventions. To date, much of the alcohol-cessation research present pilot study would still be useful. For example, the reported in the literature has been performed outside the ED Paddington Alcohol Test, also designed to screen patients for setting, often consisting of pooled data and meta-analyses.6 alcohol-related disorders in EDs, consists of only three ques- However, several studies have demonstrated the efficacy of ED tions.20 SBIR programs, finding short-term reductions in alcohol con- We enhanced physician and nurse participation in the sumption and in repeat visits to the ED.5,17 present study by placing the SBIR tool on each new patient The severe time constraints already faced by overwhelmed record, alleviating the logistical paper barrier and providing ref- ED staff is a considerable barrier to implementing SBIR pro- erence materials at point-of-care. An ongoing incentive pro-

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gram further enhanced staff participation, as did publicity 12. Amos A, Currie CE, Hunt SM. A comparison of the consistency of self- reported behavioural change within a study sample: postal versus home from local media outlets. interviews. Health Educ Res. 1991;6:479-486. Even with the successes of the present pilot study, we had 13. Robertson LS. Causes and prevention of motor vehicle injuries. Epi- limited subject follow-up, reaching a total of only 15 (0.96%) of demiology. 2004;15:350-351. the 1556 screened individuals. Larger studies would require sub- 14. Satre DD, Kohn CS, Weisner C. Cigarette smoking and long-term alcohol stantially more resources and effort in obtaining reliable con- and drug treatment outcomes: a telephone follow-up at five years. Am J tact information for subjects to allow better patient follow-up. Addict. 2007;16:32-37. 15. Friend KB, Pagano ME. Changes in cigarette consumption and drinking Conclusion outcomes: findings from Project MATCH. J Subst Abuse Treat. 2005;29:221- The present study demonstrates that the development of a 229. brief but effective SBIR program for patients with alcohol- 16. Stockwell T, Donath S, Cooper-Stanbury M, Chikritzhs T, Catalano P, related disorders can be accomplished in the ED. However, Mateo C. Under-reporting of alcohol consumption in household surveys: a comparison of quantity-frequency, graduated-frequency and recent recall. Addic- challenges remain in obtaining patient follow-up for quanti- tion. 2004;99:1024-1033. fying the impact of the ED intervention. The intervention used 17. Wright S, Moran L, Meyrick M, O’Connor R, Touquet R. Intervention by with subjects in the present study appeared to reduce at-risk an alcohol health worker in an accident and emergency department. Alcohol behaviors in individuals contacted at 6-month follow-up. Alcohol. 1998;33:651-656. Available at: http://alcalc.oxfordjournals.org/cgi /reprint/33/6/651. Accessed June 12, 2007. References 18. Mello MJ, Nirenberg TD, Longabaugh R, Woolard R, Minugh A, Becker 1. Chen CM, Yi H, Smothers BA. Trends in Alcohol-Related Morbidity Among B, et al. Emergency department brief motivational interventions for alcohol Short-Stay Community Hospital Discharges, United States, 1979-2002. Rockville, with motor vehicle crash patients. Ann Emerg Med. 2005;45:620-625. Md: Alcohol Epidemiologic Data System, National Institute on Alcohol Abuse 19. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol prob- and Alcoholism; August 2004. Surveillance Report No. 68. lems: a review. Addiction 1993;88:315-335. 2. Harwood HJ. Updating estimates of the economic costs of alcohol abuse 20. Barrett B, Byford S, Crawford MJ, Patton R, Drummond C, Henry JA, et in the United States: estimates, update methods, and data [National Institute al. Cost-effectiveness of screening and referral to an alcohol health worker on Alcohol Abuse and Alcoholism Web site]. December 2000. Available at: in alcohol misusing patients attending an accident and emergency department: http://pubs.niaaa.nih.gov/publications/economic-2000/index.htm. Accessed a decision-making approach. Drug Alcohol Depend. 2006;81:47-54. Epub June 12, 2007. July 11, 2005. 3. Cherpitel CJ. Drinking patterns and problems: a comparison of primary care with the emergency room. Subst Abuse. 1999;20:85-95. 4. Runge J. Put the brakes on the next drunk driver. Lecture presented at: American College of Emergency Physicians Scientific Assembly 2002; October 6, 2002; Seattle, Wash. 5. Crawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, et al. Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomized controlled trial. Lancet. 2004;364:1334-1339. 6. D’Onofrio GD, Degutis LC. Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med. 2002;9:627-638. Available at: http://www.aemj.org/cgi/content/abstract/9/6/627. Accessed June 12, 2007. 7. Allen JP, Wilson VB, eds; National Institute on Alcohol Abuse and Alco- holism. Assessing Alcohol Problems: A Guide for Clinicians and Researchers. 2nd ed. Washington, DC: US Dept of Health and Human Services, Public Health Service. NIH Pub No. 03-3745. Available at: http://pubs.niaaa.nih.gov /publications/Assesing%20Alcohol/index.htm. Accessed June 13, 2007. 8. D’Onofrio G, Bernstein E, Bernstein J, Woolard R, Brewer P, Craig S, et al; for the SAEM Task Force on Substance Abuse. Patients with alcohol problems in the emergency department, part 1: improving detection. Acad Emerg Med. 1998;5:1200-1209. 9. Hungerford DW, Pollock DA, eds. Alcohol Problems Among Emergency Department Patients: Proceedings of a Research Conference on Identification and Intervention. Atlanta, Ga: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2002:79-84. 10. Cherpitel CJ. Screening for alcohol problems in the emergency department. Ann Emerg Med. 1995;26:158-166. 11. Friedmann PD, Saitz R, Gogineni A, Zhang JX, Stein MD. Validation of the screening strategy in the NIAAA Physicians’ Guide to Helping Patients with Alcohol Problems. J Stud Alcohol. 2001;62:234-238.

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Appendix Screening, brief intervention, and referral (SBIR) tool for alcohol-related disorders. This form was developed by Aaron Craig Love, DO; Marna Rayl Greenberg, DO; Matthew Brice, DO; and Michael Weinstock, MD, and was based on the three at-risk questions for current drinkers recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the four-question CAGE (Cut down, Annoyed, Guilty, Eye opener) questionnaire.7,10,11 At-risk and intervention guidelines from the NIAAA are also included. To enhance staff participation, researchers obtained institutional permission to place the SBIR tool on each new patient record, alleviating the logistical paper barrier and providing point-of-care reference.

Lehigh Valley Hospital and Health Network Screen for Alcohol Problems Instructions: To be completed by a physician or nurse. Ask current drinkers the following questions. Fill in or check the patient’s responses. Sign form at bottom. _____ Check here if patient refuses to answer.

NIAA At-Risk Screen 1. On average, how many days per week do you drink alcohol? _____ days/week 2. On a typical day when you drink, how many drinks do you have? _____ drinks/day 3. What is the maximum number of drinks you had on a given occasion in the last month? _____ drinks

CAGE Screen Within the past year, 4. have you felt you ought to cut down on your drinking? ____ Yes ____ No 5. have you been annoyed by people criticizing your drinking? ____ Yes ____ No 6. have you felt guilty about your drinking? ____ Yes ____ No 7. have you had a drink first thing in the morning (ie, an eye opener) to steady your nerves, get rid of a hangover, or get your day started? ____ Yes ____ No

Readiness-to-Change Ruler Instructions: Circle one number. (Least Ready) 0 1 2 3 4 5 6 7 8 9 10 (Most Ready)

NIAAA At-Risk Drinking Guidelines Sex/Age No. of Drinks/Wk No. of Drinks per Occasion Men, р65 Years Ͼ14 Ͼ4 Men, Ͼ65 Years Ͼ7 Ͼ3 Women, All Ages Ͼ7 Ͼ3

Standard drink = 1.5 oz spirits; 5 oz wine; 12 oz beer. (continued)

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Appendix (continued)

Lehigh Valley Hospital and Health Network Screen for Alcohol Problems (continued) Intervention Guidelines

Result of Screen Basic Intervention Primary Intervention Negotiable Intervention Negative Counsel regarding Counsel to not .... safe drinking habits. drink and drive.

At Risk Counsel on moderate-to- Follow-up with primary Refer to Alcoholics (Based on NIAAA safe drinking. care provider. Anonymous if guidelines or CAGE = 1) Advise about health risks. deemed clinically useful.

Dependent Recommend goal toward Follow-up with primary Consult with Psychiatric (Based on CAGEу2 abstinence. care provider. Emergency Services in or clinical diagnosis) Advise about health risks. Refer to Alcoholics emergency department. Anonymous/specialized alcohol treatment.

This form is NOT part of the permanent medical record; it is for internal quality-improvement purposes only. ______Physician Nurse

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