DIAL: a randomised trial of a telephone brief intervention for alcohol.

BACKGROUND: Decreasing Injuries from ALcohol (DIAL) is a randomised control trial of a telephone brief intervention (BI) with injured emergency department (ED) patients with high-risk alcohol use. Here the authors examine 12-month outcomes of the intervention's effect on alcohol use, alcohol-related injuries and alcohol-related negative consequences. METHODS: ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, all participants received by telephone an assessment of their alcohol use, alcohol-related injuries, and alcohol-related negative consequences and then were randomised to treatment or standard care. Treatment consisted of two telephone sessions of BI focusing on risky alcohol use. Both groups were reassessed after 12 months. RESULTS: At 12 months, 249 (89%) participants completed follow-up assessments. After using a log transformation, the difference in alcohol-related injuries between baseline and 12-month follow-up was greater in the BI group than the standard care group (p=0.04); this is an effect size of Cohen's d=0.21. No difference between groups was found when comparing change in alcohol consumption and other alcohol-related negative consequences at 12 months. CONCLUSIONS: These findings suggest that a telephone BI with injured ED patients may decrease alcohol-related injuries. Identifying patients with risky alcohol use in the ED and then subsequently delivering the intervention by telephone after discharge has promise as a model for BI and deserves further study.

Feasibility and acceptability of a pediatric emergency department alcohol prevention intervention for young adolescents.

OBJECTIVE: The objective of this study was to determine feasibility and acceptability of a brief pediatric emergency department (PED) prevention intervention to delay/prevent initiation of alcohol use in 12-to 14-year-olds. METHODS: Medically stable 12- to 14-year-olds presenting to the PED who were accompanied by a parent and who had not initiated alcohol use were eligible. Adolescent-parent dyads completed a computerized assessment and were randomized to either brief targeted prevention intervention (BPI) or enhanced standard care (ESC). Families randomized to BPI participated in a PED-based motivational interviewing and skill building-based session with a trained counselor. Parents randomized to BPI had telephone boosters at 1 and 3 months. Families randomized to ESC received standard care and adolescent substance use pamphlets. All dyads completed 6-month follow-up assessments to assess alcohol use-related outcomes. RESULTS: Two hundred twenty-eight families were approached: 122 were eligible and 104 were enrolled (85%). Mean youth age was 13 (SD, 0.83) years, 51% were female, and 90% of parents were females. Of the 104 enrolled, 5 withdrew; 99 (94%) completed the assessment battery in the PED in less than 30 minutes. All BPI dyads completed the counseling session in the PED. However, only 53% of BPI parents completed the booster telephone sessions. Brief targeted prevention intervention acceptability items were rated favorably (82%-100%) by both parents and adolescents. There were no differences between BPI and ESC on substance-related outcomes, although the study was not adequately powered for this purpose because it was designed as a feasibility study. CONCLUSIONS: A BPI in the PED is both feasible and acceptable, but phone boosters proved less feasible. Larger samples and further study are needed to identify efficacy of the BPI in delaying onset of alcohol use in teens.

Interrelationship of alcohol misuse, HIV sexual risk and HIV screening uptake among emergency department patients.

BACKGROUND: Emergency department (ED) patients comprise a high-risk population for alcohol misuse and sexual risk for HIV. In order to design future interventions to increase HIV screening uptake, we examined the interrelationship among alcohol misuse, sexual risk for HIV and HIV screening uptake among these patients. METHODS: A random sample of 18-64-year-old English- or Spanish-speaking patients at two EDs during July-August 2009 completed a self-administered questionnaire about their alcohol use using the Alcohol Use Questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), and the HIV Sexual Risk Questionnaire. Study participants were offered a rapid HIV test after completing the questionnaires. Binging (≥ five drinks/occasion for men, ≥ four drinks for women) was assessed and sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, dependence) were calculated using AUDIT scores. Analyses were limited to participants who had sexual intercourse in the past 12 months. Multivariable logistic regression was used to assess the associations between HIV screening uptake and (1) alcohol misuse, (2) sexual risk for HIV, and (3) the intersection of HIV sexual risk and alcohol misuse. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics and separate models for men and women were constructed. RESULTS: Of 524 participants (55.0% female), 58.4% identified as white, non-Hispanic, and 72% reported previous HIV testing. Approximately 75% of participants reported drinking alcohol within the past 30 days and 74.5% of men and 59.6% of women reported binge drinking. A relationship was found between reported sexual risk for HIV and alcohol use among men (AOR 3.31 [CI 1.51-7.24]) and women (AOR 2.78 [CI 1.48-5.23]). Women who reported binge drinking were more likely to have higher reported sexual risk for HIV (AOR 2.55 [CI 1.40-4.64]) compared to women who do not report binge drinking. HIV screening uptake was not higher among those with greater alcohol misuse and sexual risk among men or women. CONCLUSIONS: The apparent disconnection between HIV screening uptake and alcohol misuse and sexual risk for HIV among ED patients in this study is concerning. Brief interventions emphasizing these associations should be evaluated to reduce alcohol misuse and sexual risk and increase the uptake of ED HIV screening.

Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers.

Brief motivational interventions (BMIs) are usually effective for reducing alcohol use and consequences in primary care settings. We examined readiness to change drinking as a mediator of the effects of BMI on alcohol-related consequences. Participants were randomized into three conditions: (a) standard care plus assessment (SC), (b) SC plus BMI (BI), and (c) BI plus a booster session (BIB). At 12-month follow-up BIB patients had significantly reduced alcohol consequences more than had SC patients. Patients receiving BI or BIB maintained higher readiness scores 3 months after treatment than did patients receiving SC. However, readiness mediated treatment effects only for those highly motivated to change prior to the intervention but not for those with low pre-intervention motivation. BI and BIB for these patients decreased alcohol consequences in part because they enhanced and maintained readiness for those highly motivated prior to the intervention, but not for those with low motivation. Results are opposite of what would be expected from MI theory. An alternative explanation is offered as to why this finding occurred with this opportunistically recruited Emergency Department patient population.

Do patient intervention ratings predict alcohol-related consequences?

Little is known about treatment process for behavior change for brief interventions. Patient ratings of treatment process during a patient-centered brief intervention for alcohol were used to predict post-treatment alcohol use and consequences. We use data from a randomized clinical trial that compared the effects of BI (1 session) to BI and booster (BIB, 2 sessions) to reduce harmful drinking and alcohol consequences. Subjects were n=167 (BI) and n=82 (BIB). Five of the 12 ratings were rated significantly higher by those in the BIB condition compared to BI. The only predictor of reduced alcohol consequences at 12-months was higher ratings of, "I have obtained some new understanding," for BIB participants (t=-2.50, p<.05). Patient perspectives on treatment may have a role in patient outcomes and should be explored as a dimension of treatment process.

Emergency department brief motivational interventions for alcohol with motor vehicle crash patients.

STUDY OBJECTIVE: This study compares the effect of a brief motivational intervention for alcohol plus a booster given to emergency department (ED) patients with subcritical injuries from a motor vehicle crash with the effect of brief motivational intervention for alcohol plus a booster in patients treated for non-motor vehicle crash-related injuries. METHODS: A randomized controlled trial (n=539) was conducted at an urban Level I trauma center of brief intervention (1 ED session of brief intervention), brief motivational intervention for alcohol plus a booster (1 ED session plus booster session), or standard care for injured ED patients with an alcohol use problem who were being discharged home. At 12 months, alcohol-related negative consequences and injuries were measured. We performed a secondary analysis comparing motor vehicle crash-injured patients and non-motor vehicle crash-injured patients in the study sample. RESULTS: Subcritically injured ED patients with harmful or hazardous alcohol use who received brief motivational intervention for alcohol plus a booster had fewer alcohol-related negative consequences and alcohol-related injuries than those receiving brief intervention or standard care at 12-month follow-up (previously reported). A secondary analysis of this result showed that motor vehicle crash patients (n=133) given brief motivational intervention for alcohol plus a booster (n=34) had fewer alcohol-related injuries than those receiving standard care (n=46; P =.001). Moreover, there were no significant differences in alcohol-related injuries among the non-motor vehicle crash-injured patients who received brief intervention or standard care. CONCLUSION: Brief motivational intervention for alcohol plus a booster is a useful intervention for subcritically injured ED patients with harmful or hazardous alcohol use. Its effects may be moderated by the cause of injury.

Can the short index of problems (SIP) be improved? Validity and reliability of the three-month SIP in an emergency department sample.

OBJECTIVE: Although the Short Index of Problems (SIP) is often used, little is known about the psychometric properties of the SIP in special populations. The present study seeks to determine the following: (1) whether it is possible to substitute items to enhance the psychometric properties of the SIP and (2) whether the SIP, or improved scale, is as sensitive as the Drinker Inventory of Consequences (DrInC) to assess intervention effectiveness. METHOD: The sample consisted of 404 injured patients who were treated in the Emergency Department (ED) of a major teaching hospital that serves southern New England. Three approaches were used to guide development of the 3-month SIP-R, the potential alternative to the SIP. Cronbach's alpha assessed intrascale reliability; hierarchical multiple regression assessed construct validity; performance of the scales assessing intervention change were compared to the total 3-month DrInC as a function of intervention using analysis of covariance (ANCOVA). RESULTS: There was no evidence that changing the current SIP items will significantly improve performance. The 3-month SIP performed as well as the 3-month DrInC-2R in predicting 12-month DrInC scores and in determining intervention change at 12 months. Of the 45 DrInC items, 31 also predicted a difference across intervention groups. CONCLUSIONS: These results suggest there is no advantage to changing the current SIP items. The 3-month SIP is a psychometrically sound measure for assessing consequences of alcohol consumption in an ED sample and is almost as sensitive to intervention change as the full DrInC.

Research fundamentals: follow-up of subjects in clinical trials: addressing subject attrition.

Many published clinical trials have less than adequate follow-up. When conducting a clinical trial, researchers attempt to minimize data loss; however, some data may not be collected, particularly when subjects are lost to follow-up. Careful planning of research protocols, including comprehensive initial data collection, identification of locators, flexible scheduling, systematic subject tracking, monitoring subject loss, and systematically approaching problem cases can ensure high follow-up rates. This article presents a compendium of techniques and procedures that researchers can use to enhance follow-up and address attrition in their studies. Finally, this article outlines statistical techniques that can be used to address the effects of missing data, particularly when patients are lost to follow-up.

Marijuana use and prior injury among injured problem drinkers.

OBJECTIVES: The purpose of this paper is to better understand marijuana use among injured problem drinkers in the emergency department (ED). The specific objectives are: 1) to assess the prevalence of marijuana use; 2) to identify factors associated with marijuana use; 3) to determine whether prior injury is associated with marijuana use; and 4) to determine whether marijuana-using problem drinkers want to change behaviors. METHODS: The authors conducted a post-hoc analysis on data obtained prospectively. Subjects had injury and problem drinking: either measurable alcohol level (blood alcohol concentration, BAC), report of drinking, or an Alcohol Use Disorders Identification Test (AUDIT) score of > or =8. The study was conducted on weekend nights; 3,776 injured ED patients were screened, 383 refused, 578 were enrolled, and 433 had complete data. RESULTS: Of the 433 subjects, 48.3% reported using marijuana in the three months prior. Marijuana-using problem drinkers had more hazardous drinking, higher AUDIT scores (14.0 vs. 11.4, p < 0.001), and higher risk-taking scores (12.4 vs. 10.1, p < 0.001). More used other drugs (69.7% vs. 30.3%, p < 0.001). In regression analyses, marijuana use remained an independent predictor of prior injury (OR = 2.16, 95% CI = 1.25 to 3.75), particularly prior alcohol-related (OR = 2.26, 95% CI = 1.45 to 3.53) and motor-vehicle-related (OR = 1.69, 95% CI = 1.03 to 2.79) injury. Readiness-to-change scores were similar (4.14 vs. 4.22, p = 0.21) between users and nonusers. CONCLUSIONS: Marijuana use among injured problem drinkers is prevalent. Their risk of prior injury is increased. Counseling for alcohol and injury should address marijuana use.

Brief intervention to increase emergency department uptake of combined rapid human immunodeficiency virus and hepatitis C screening among a drug misusing population.

OBJECTIVES: In this study, Increasing Viral Testing in the Emergency Department (InVITED), the authors investigated if a brief intervention about human immunodeficiency virus (HIV) and hepatitis C virus (HCV) risk-taking behaviors and drug use and misuse in addition to a self-administered risk assessment, compared to a self-administered risk assessment alone, increased uptake of combined screening for HIV and HCV, self-perception of HIV/HCV risk, and impacted beliefs and opinions on HIV/HCV screening. METHODS: InVITED was a randomized, controlled trial conducted at two urban emergency departments (EDs) from February 2011 to March 2012. ED patients who self-reported drug use within the past 3 months were invited to enroll. Drug misuse severity and need for a brief or more intensive intervention was assessed using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Participants were randomly assigned to one of two study arms: a self-administered HIV/HCV risk assessment alone (control arm) or the assessment plus a brief intervention about their drug misuse and screening for HIV/HCV (intervention arm). Beliefs on the value of combined HIV/HCV screening, self-perception of HIV/HCV risk, and opinions on HIV/HCV screening in the ED were measured in both study arms before the HIV/HCV risk assessment (pre), after the assessment in the control arm, and after the brief intervention in the intervention arm (post). Participants in both study arms were offered free combined rapid HIV/HCV screening. Uptake of screening was compared by study arm. Multivariable logistic regression models were used to evaluate factors related to uptake of screening. RESULTS: Of the 395 participants in the study, the median age was 28 years (interquartile range [IQR] = 23 to 38 years), 44.8% were female, 82.3% had ever been tested for HIV, and 67.3% had ever been tested for HCV. Uptake of combined rapid HIV/HCV screening was nearly identical by study arm (64.5% vs. 65.2%; Δ = -0.7%; 95% confidence interval [CI] = -10.1% to 8.7%). Of the 256 screened, none had reactive HIV antibody tests, but seven (2.7%) had reactive HCV antibody tests. Multivariable logistic regression analysis results indicated that uptake of screening was not related to study arm assignment, total ASSIST drug scores, need for an intervention for drug misuse, or HIV/HCV sexual risk assessment scores. However, uptake of screening was greater among participants who indicated placing a higher value on combined rapid HIV/HCV screening for themselves and all ED patients and those with higher levels of perceived HIV/HCV risk. Uptake of combined rapid HIV/HCV screening was not related to changes in beliefs regarding the value of combined HIV/HCV screening or self-perceived HIV/HCV risk (post- vs. pre-risk assessment with or without a brief intervention). Opinions regarding the ED as a venue for combined rapid HIV/HCV screening were not related to uptake of screening. CONCLUSIONS: Uptake of combined rapid HIV/HCV screening is high and considered valuable among drug using and misusing ED patients with little concern about the ED as a screening venue. The brief intervention investigated in this study does not appear to change beliefs regarding screening, self-perceived risk, or uptake of screening for HIV/HCV in this population. Initial beliefs regarding the value of screening and self-perceived risk for these infections predict uptake of screening.

The effect of group-adapted motivational interviewing on traffic convictions and driving behaviors of court-adjudicated youth.

OBJECTIVE: To evaluate the effect of a 20 hr prevention program (The Reducing Dangerous Driving Program, RYDD) in reducing traffic citation recidivism and high-risk driving behaviors among 16- to 20-year-olds referred by the Rhode Island courts for traffic citation events. METHODS: Participants were randomized to receive either the Adapted Group Motivational Interviewing (AGMI) or the Community Service (CS) arm of the study. Participants completed a survey at baseline and at 6 and 12 months post-RYDD completion. Objective court data on post-RYDD traffic event citations were also collected. RESULTS: There were no significant differences between the groups on measures of high-risk driving behaviors and post-RYDD traffic event citation recidivism at the 12-month follow-up assessment. CONCLUSIONS: There remains a need to develop and test behavioral interventions that could address high-risk driving behaviors and associated motor vehicle crash (MVC) risk in this population. Further research is needed to determine whether group behavioral interventions that use motivational interviewing could be a possible mechanism for changing high-risk behaviors, traffic citation recidivism, and the associated risks that these pose for MVCs among young drivers.

Sex differences in alcohol misuse and estimated blood alcohol concentrations among emergency department patients: implications for brief interventions.

OBJECTIVES: The objective was to assess the relationship between alcohol use and misuse and patient sex among emergency department (ED) patients by comparing self-reported estimates of quantity and frequency of alcohol use, estimated blood alcohol concentrations (eBACs) when typically drinking and during heavy episodic drinking (binging), and alcohol misuse severity, to understand sex differences in alcohol use and misuse for this population. METHODS: The authors surveyed a random sample of nonintoxicated, subcritically ill or injured, 18- to 64-year-old English- or Spanish-speaking patients on randomly selected dates and times at two EDs during July 2009 and August 2009. Participants self-administered a questionnaire about their self-reported alcohol use during a typical month within the past 12 months and the Alcohol Use Disorders Identification Test (AUDIT). Using the formulae by Matthews and Miller, sex-specific eBACs were calculated for participants according to their reported weight and the number of reported alcoholic drinks consumed on days when typically drinking and on days of heavy episodic (binge) drinking (five or more drinks/occasion for men, four or more drinks for women). Sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, and dependence) were calculated using AUDIT scores. Wilcoxon rank-sum and Pearson's chi-square tests were used to compare outcomes by sex. Negative binomial regression was used to assess the relationship between sex and the number of drinks consumed on a typical day, the number of days spent drinking and binging, and estimated AUDIT scores. Logistic regression was used to assess the outcome of the presence of binging according to sex. Multinomial logistic regression was used to compare by sex the percentage of days spent drinking and binging in 1 month, eBACs when typically drinking and when binging, and AUDIT at-risk drinking levels. Incidence rate ratios (IRRs) and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics. RESULTS: Of the 513 participants, 52.1% were women, 55.8% were white non-Hispanic, and their median age was 34 years (interquartile range [IQR] = 25 to 46 years). Men reported greater mean alcohol consumption than women when typically drinking (4.3 vs. 3.3 drinks/day; p < 0.001) and during heavy episodic drinking (8.6 vs. 5.3 drinks/occasion; p < 0.001). Men spent more days drinking (IRR = 1.41, 95% CI = 1.19 to 1.65) and engaging in heavy episodic drinking (IRR = 1.68, 95% CI = 1.31 to 2.17) than women. Additionally, men were more likely to engage in heavy episodic drinking (AOR = 1.72, 95% CI = 1.16 to 2.56) than women. However, the mean eBACs for men and women were similar when typically drinking (0.05 vs. 0.06; p < 0.13) and during heavy episodic drinking (0.13 vs. 0.12; p < 0.13). Mean AUDIT scores were greater for men than women (7.5 vs. 5.3; p < 0.001), although alcohol misuse severity levels were similar between men and women (24.4% vs. 26.6% for hazardous, 2.8% vs. 2.2% for harmful, and 6.5% vs. 3.4% for dependence; p < 0.38). CONCLUSIONS: Although men drink more than women, women have similar eBACs with comparable levels of alcohol misuse. Women may benefit from recognizing that they are reaching similar levels of intoxication compared to men. Addressing these differences and possible health implications in future ED brief interventions may induce changes in problematic alcohol use among women.

Change plan as an active ingredient of brief motivational interventions for reducing negative consequences of drinking in hazardous drinking emergency-department patients.

OBJECTIVE: Few studies have examined the effects of brief motivational intervention components, such as change-plan completion, on treatment outcomes. This secondary analysis of an opportunistically recruited emergency-department sample of hazardous injured drinkers examines the potential predictive role of an alcohol-related change plan on treatment outcomes after accounting for pretreatment readiness. Written change plans were independently rated. METHOD: A mediational analysis framework tested directional hypotheses between pretreatment readiness, change plan, and treatment outcomes using linear regressions. The baseline total Drinker Inventory of Consequences (DrInC) score was covaried on 12-month DrInC total score, in all analyses. Participants who completed a brief motivational intervention and a change plan were included (N = 333). RESULTS: Pretreatment readiness was negatively associated with alcohol consequences at 12 months, (beta = -.09, t(254) = -2.07, p < .05, and good-quality change plans, (beta = .18, t(320) = 4.37, p < .001. With change plan and readiness in the same model, the relationship between readiness and treatment outcomes became nonsignificant, but change plan remained a significant predictor of treatment outcomes in the expected direction, beta = -.17, t(254) = -2.89, p < .01. Follow-up generalized linear modeling including an interaction term (change plan and pretreatment readiness) revealed that those with high readiness and a good-quality change plan versus those with low readiness and a poor-quality change plan had better-than-predicted outcomes for either readiness or change plan alone. CONCLUSIONS: Study findings suggest that the change plan in brief motivational intervention may be an active ingredient of treatment associated with better outcomes over and above the influence of pretreatment readiness.

Project integrate: translating screening and brief interventions for alcohol problems to a community hospital emergency department.

Screening and brief intervention (SBI) for alcohol problems in the emergency department (ED) is effective. The objective of this study was to examine the translation of SBI into a busy community ED environment. The authors assessed key stakeholders views of SBI delivery model, then utilized feedback to adapt model. Adoption of SBI was recorded, with data collected on use of screening tool, and referral for a BI. Model was modified due to physicians' and nursing resistance; physicians only screened and a research assistant (RA) delivered the BI. When the RA was present, screening by ED staff increased from 50% to 71% but returned to 50% after the RA left. An identified opportunity was increased nursing interest after observation of SBI, with 15 nurses trained in SBI after ED intervention concluded. Important barriers to translating SBI to community ED clinical practice exist. However, with additional staff present, high levels of SBI can occur.

A cross-sectional study of the self-report of stress among emergency department patients.

BACKGROUND: There is a lack of information about the prevalence of stress and types of stressors experienced by Emergency Department (ED) patients. OBJECTIVE: The present aim is to study the prevalence of stress, types of stressful situations and the relationship with other health issues within the ED population. MATERIALS AND METHODS: This is a cross-sectional study performed in an ED at a level-1 urban trauma center for four months. An anonymous survey was offered to adult non critically ill patients who were admitted in the ED. They were divided on the basis of gender, age and level of stress and were asked about their demographics, reasons for their ED visit and health issues including stress, tobacco, alcohol and marijuana use, weight concern and health. Chi-square for the categorical variables and unpaired t-tests for continuous variables were conducted. RESULTS: We interviewed 1797 patients, over 66% reported that they felt stressed on at least a weekly basis, and over 45% indicated that they felt stressed more than twice per week. While both young and old were equally stressed, females reported significantly more stress. Family, finances and work are the most frequently cited stressors. Different age groups reported different types of stressors. Overall, those patients reporting being stressed more frequently reported more high risk behaviors including cigarette and marijuana use and health problems including being overweight, being depressed, and having sleeping problems and chronic fatigue. CONCLUSIONS: Considering the high frequency of ED patients that report frequent stress and high risk behaviors, their ED visit may be an excellent opportunity to provide a referral or an intervention for stress reduction.