The Emergency Department as a prevention site: a demographic analysis of substance use among ED patients.

OBJECTIVES: To identify rates of alcohol and drug use among patients presenting to an inner-city Emergency Department (ED) and to describe demographic and health characteristics of patients with high-risk use. METHODS: A cross-sectional study of patients presenting to the ED for any complaint. Patients were administered a brief screening about past 12-months alcohol and drug use. Patients who answered "yes" to any question were approached for a longer survey, the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Based on ASSIST scores patients received a brief intervention, and, when appropriate, a referral for brief outpatient therapy or specialized substance abuse treatment. Patients whose score indicated high-risk or dependent use were also asked demographic and health questions. RESULTS: Over a 20-month period, 19,055 patients were pre-screened. 87.1% of patients were black, 57% were male, with average age 44.8 years. 27.6% of patients pre-screened positive for drug or alcohol use; among these patients 44.2% scored in the low-risk range on the ASSIST, 35.8% moderate risk, 10% high risk and 10% probable dependence. Among patients with high-risk or dependent use, 70% rated their current health as fair/poor, with a mean of 1.7 ED visits in the prior 30 days. 40.7% reported "extreme" stress due to their use. 34.6% reported that they had stable housing and 13.6% were fully employed. CONCLUSION: Among all patients seen in the ED for any complaint, a significant proportion is engaged in alcohol and drug use that increases their risk of health and social consequences.

Patient versus therapist alliance: whose perception matters?

Development of working alliance was examined for 25 opioid-abusing pain patients and their therapists. Patients participated in an eight-session intervention based on adherence strategies and employment of a supportive, psychoeducational approach; methadone was prescribed for pain. Treatment goals included opioid analgesic adherence and decreasing pain, functional interference, and substance abuse. Patients and therapists completed the Helping Alliance Questionnaire-II following each treatment session. At baseline, scores of patients and therapists indicated good alliance. Patient alliance grew significantly over time regardless of addiction severity and independent of treatment outcomes. In contrast, therapist alliance grew only for patients without substance abuse comorbidity and/or who had good outcomes. Patients' and therapists' alliance scores were consistent during sessions focused on emotional bonds but diverged during sessions that demanded behavior change, suggesting that therapists may have reacted negatively to patients' lack of progress. Whether therapists' reactions to poor performers impacted subsequent patient outcomes is unknown but should be investigated.