Brief Interventions for Alcohol Abuse in the Emergency Department
Search Strategy: You conduct a therapy Pubmed Clinical Query using the term “alcoholism” broad/sensitive search revealing 15611 articles (see http://tinyurl.com/7uakeha). Next, you conduct an unfiltered search for “inpatient treatment” and combine it with the results from the first search (see http://tinyurl.com/7rpe4al). This strategy yields 558 citations, including all four of the articles below.
During an overwhelmingly busy EM2 shift in which you have already intubated two patients and transferred another three to the trauma bay for acute medical instability, you evaluate a 23-year old law student who is an alcoholic. He has been failing his classes, which he has not attended in weeks. He lives alone in an apartment, supported by his parents. Two days earlier he had been brought in by EMS when he was not answering his telephone. At that time his mother, who lives in Los Angeles, had asked local EMS to break down his door and transport him to the hospital. Once sober, he refused to stay and declined help. The situation occurred again tonight, but this time his mother got on a plane and came directly to his apartment. At her insistence, he had him come to the ED. He does not want to be in the ED, but his mother insists that “Somebody has to help him.” Last semester he completed an inpatient alcohol dependency program in Phoenix, again at her insistence. Faced with multiple disgruntled patients in your ED demanding initial evaluations, test results, and/or dispositions you ponder the benefit of alcohol treatment programs when the patient has marginal interest at that time in sobriety…and the role of emergency medicine in intervening upon this particular addictive pathology which society often neglects.
Population: Adult ED, inpatients, or outpatients with alcoholism
Intervention: Brief alcoholism interventions
Comparison: No alcohol intervention
Outcome: Abstinence rates and duration, alcohol-related morbidity & mortality, cost-effectiveness
First years: Effectiveness of brief interventions after alcohol-related vehicular injury: A randomized controlled trial, J Trauma 2006; 61: 523-533. (http://pmid.us/15464318)
Second years: Brief intervention for medical inpatients with unhealthy alcohol use: A randomized controlled trial, Ann Intern Med 2007; 146: 167-176. (http://pmid.us/17283347)
Article 1: Effectiveness of brief interventions after alcohol-related vehicular injury: A randomized controlled trial, J Trauma 2006; 61: 523-533.
Article 2: Brief intervention for medical inpatients with unhealthy alcohol use: A randomized controlled trial, Ann Intern Med 2007; 146: 167-176.
Article 3: Brief interventions for heavy alcohol users admitted to general hospital wards, Cochrane Database Syst Rev 2011; (8):CD005191.
Article 4: Brief alcohol intervention for general hospital inpatients: A randomized controlled trial, Drug Alcohol Depend 2008; 93: 233-243.
Is alcohol use/abuse really a problem for emergency medicine? Worldwide over 76-million people have alcohol use disorders with 2.3-million alcohol-related premature deaths each year as a result of cirrhosis, cancers, and injuries. For example, alcohol is estimated to contribute to 20%-30% of esophageal cancer, liver cancer, cirrhosis, homicide, and epilepsy. In fact, about 4.5% of the global burden of disease and injury are attributable to alcohol. Each alcoholic negatively affects an average of four other individuals. In the United Kingdom 41% of emergency department patients have alcohol detected when tested and alcohol use costs the British healthcare system £1.7-billion annually (£2003) and is responsible for more direct costs to society than health, social, and criminal justice systems than Alzheimer’s disease, schizophrenia, or stroke. In the United States the Institute of Medicine and US Preventive Services Task Force both recommend brief interventions for medical inpatients with unhealthy alcohol use patterns. The bad news is that alcohol consumption continues to increase each year globally.
Therefore, it would appear that there is a problem and that the problem directly impacts/interfaces with emergency medicine. The next question is what can be done in the busy emergency department environment to reduce alcohol-related adverse health effects? Beyond a simple statement to “reduce drinking” or “seek help”, most of us lack the behavioral modification training that our colleagues in social work and Psychiatry possess. Therefore, understanding this literature is challenging. For example, the four manuscripts we reviewed in Journal Club were reviewed by one Washington University interventionists Psychiatrist who had several concerns about their potential design-related biases:
- Each study has a significant “placebo effect” which undermines one’s ability to detect treatment-attributable effects. The “placebo effect” reflects tangible treatments penetrating control interventions or poor reliability of outcome measures. “Most of us in the intervention business try to construct our studies so that minimal change is seen in the control group, and we typically do pilot studies to confirm this before moving into big confirmatory studies.”
- None of the studies reported evidence of “treatment fidelity”. How faithfully did the therapists adhere to the motivational interviewing protocol? How competently did the therapists provide motivational interviewing. For example, in the PGY II article the treatment group did not even demonstrate a difference for change in readiness which is fundamentally what motivational interviewing accomplishes. A lack of change in that variable would suggest that the counselors were not really performing motivational interviewing correctly. “Poor treatment fidelity can (and often does) undermine behavior intervention research, and the fact that the articles stated that the interventionists (students, nurses, physicians) were trained, supervised, taped, and rated is not enough to assure that the treatment was done correctly and competently”.
- Overall, a small intervention (brief counseling in the emergency department) will yield a small effect size, but that doesn’t mean that it should not be done.
With these caveats in mind, here are the group’s consensus about each of the four articles we reviewed. The conclusions from each manuscript are reported separately because the methods and patient populations differ too much to lump the research together under one “bottom line”.
PGY I article: This study has too many potential flaws to yield any conclusive take-home points.
PGY II article: Although recommended by the Institute of Medicine and US Preventive Services Task Force, in this study evaluating brief interventions for medical inpatients with unhealthy alcohol use (75% were alcohol dependent), brief interventions are inadequate to link patients with assistance for dependence or to reduce alcohol consumption or alcohol-related health problems. Future trials are needed to identify pragmatic ED- and inpatient-based strategies while delineating the optimal intensities and duration that effectively reduce alcohol-related morbidity.
PGY III article (Cochrane Review): Brief interventions delivered by physicians, nurses, psychologists, or social workers to inpatients at-risk for unhealthy alcohol consumption reduces alcohol consumption at 6- and 9-months, but is not sustained and does not reduce binge drinking, driving citations, or mortality.
PGY IV article: Among middle-aged male German patients admitted to the hospital for a medical illness, 20% will screen positive for unhealthy alcohol use and half of those will meet criteria for alcohol abuse, alcohol dependence, risky drinking, or heavy episodic alcohol use. Providing an information brochure and Motivational Interviewing counseling by psychologists or physicians will not reduce alcohol consumption at 12-months any better than does routine care.
Ultimately, we concluded that future studies are needed using valid randomization schemes and pragmatic emergency department screen/treat or refer models to more accurately evaluate the effectiveness of alcohol abuse related interventions on heterogeneous emergency care populations.