Brief Intervention and
Referral to Treatment
EMERGENCY MEDICINE

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>107,000 alcohol related deaths each year
1/3 of adult hospital admissions are alcohol related
Attributable risk factor for multiple illnesses
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

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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

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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

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Under reported on death certificates
Under reported on hospital discharge
Selection and recording bias

27,500
25,000
22,500
20,000
17,500
15,000
12,500
10,000
7,500
5,000
2,500
0
Alcohol-Related Fatalities in MVCs
82 84 86 88 90 92 94 96 98 00 02 04
Source: FARS

600
500
400
300
200
100
0
BAC Levels for Alcohol Positive Drivers
Involved in Alcohol-Related Fatal Crashes
.16 = Median and Mode BAC
800
700
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

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Hazardous drinking - at-risk drinking
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NIAAA definition
Harmful drinking
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Health consequences
Binge drinking
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5 or more drinks per drinking episode

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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

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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

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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

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Alcohol use
Quantity
Frequency
Type of alcohol used
Problems related to alcohol use

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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

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Brief intervention
Further evaluation and more extensive intervention for person with more significant problem
Provider intervention may be more effective

A standard drink is 12 grams of pure alcohol or:
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•
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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

Men
Women
All Age >65
Drinks per week
> 14
> 7
> 7
Drinks per occasion
> 4
> 3
> 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.
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Binge drinking is clearly dangerous for the drinker and for society

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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

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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
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Dependence
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Advise to abstain
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Refer to treatment

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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
Maintenance
Action
Contemplation
Preparation
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