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Three Part Question

In [adults presenting to the Emergency Department with an alcohol-related event], is [Brief Intervention better than standard care] at [reducing subsequent alcohol consumption, reducing alcohol-related problems, reducing ED re-attendance and improving psychosocial well-being?]

Clinical Scenario

A 33 year old male arrives at the ED having been involved in a road traffic accident whilst driving under the influence of alcohol. You have heard about the recent institution of an Alcohol Health Service in the department comprising two designated Alcohol Health Workers who administer brief psychotherapeutic interventions to children and adults presenting with alcohol-related events. Having assessed and treated the patient, you wonder whether it is worthwhile referring him on to them...

Search Strategy

MEDLINE 1950 to July week 1 2007
EMBASE 1980 to 2007 week 28
PsycINFO 1967 to July week 2 2007
CINAHL 1982 to July week 1 2007
The Cochrane Library Issue 2, 2007
Medline:
{[(alcohol$.mp. OR ethanol.mp. OR exp Ethanol/ OR booze$.mp. OR exp Alcohol Drinking/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp Alcoholism/ OR exp Alcoholic Intoxication/]}
AND [brief intervention$.mp. OR (brief.mp. AND intervention$.mp.) OR exp Psychotherapy, Brief/ OR exp Counseling/ OR counsel$.mp. OR exp Health Personnel/ OR health worker.mp.]
AND [exp Emergency Service, Hospital/ OR emergency department$.mp. OR (accident and emergency).mp. OR exp Trauma Centers/]
LIMIT to [humans AND English language]
EMBASE:
[(alcohol$.mp. OR exp ALCOHOL/ OR ethanol.mp. OR booze$.mp. OR exp Alcohol Consumption/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp ALCOHOLISM/ OR exp Drug Dependence/ OR exp Drug Misuse/ OR exp Alcohol Abuse/ OR exp ALCOHOL INTOXICATION/]}
AND [brief intervention$.mp. OR (brief.mp. AND intervention$.mp.) OR exp PSYCHOTHERAPY/ OR exp COUNSELING/ OR counsel$.mp. OR exp Health Care Personnel/ OR health worker.mp.]
AND [exp Emergency Medicine/ OR exp Emergency Health Service/ OR emergency department$.mp. OR exp emergency ward/ OR (accident and emergency).mp. OR trauma center.mp.]
LIMIT to [humans AND English language]
PsycINFO:
{[(alcohol$.mp. OR ethanol.mp. OR exp ETHANOL/ OR booze$.mp.) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp)] OR [alcoholism.mp. OR exp ALCOHOLISM/ OR exp Alcohol Drinking Patterns/ OR exp Drug Dependency/ OR exp ALCOHOL ABUSE/ OR exp Alcohol intoxication/]}
AND [brief intervention$.mp. OR (brief.mp. AND (exp INTERVENTION/ OR intervention$.mp.)) OR exp Brief Psychotherapy/ OR exp Counseling/ OR counsel$.mp. OR exp Health Personnel/ OR health worker.mp.]
AND [exp Emergency Services/ OR emergency department$.mp. OR (accident and emergency).mp. OR trauma center$]
LIMIT to [humans AND English language]
CINAHL:
{[(alcohol$.mp. OR ethanol.mp. OR exp Alcohol, Ethyl/ OR booze$.mp. OR exp Alcohol Drinking/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp ALCOHOLISM/ OR exp Alcohol abuse/ OR exp Alcoholic Intoxication/]}
AND [brief intervention$.mp. OR (brief.mp. AND intervention$.mp.) OR exp PSYCHOTHERAPY/ OR exp COUNSELING/ OR counsel$.mp. OR exp Health Personnel/ OR health worker.mp.]
AND [exp Emergency Service/ OR emergency department$.mp. OR (accident and emergency).mp. OR exp Trauma Centers/]
LIMIT to [humans AND English language]
The Cochrane Library:
[Alcohol Drinking/ OR alcohol*.mp. OR problem drinking.mp.] AND [Psychotherapy, Brief/ OR brief intervention.mp.] AND [Emergency Service, Hospital/ OR Emergency Medical Services/ OR emergency department*.mp.]

Search Outcome

590 articles were found in all databases, of which 8 were relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Schermer 2006 USA	126 trauma patients aged 16-80 years; admission >=24 hours; injury resulting from motor vehicle crash; English-speaking; consenting; primary residence in study location; admission blood alcohol concentration >= 80mg/dL or AUDIT score >=; no brain injury requiring discharge to a rehabilitation hospital. 62 randomised to standard care (SC), 64 to brief intervention (BI) SC - patients provided with list of telephone numbers of local alcohol treatment organisations BI - by social worker or trauma surgeon; 30mins; discussion of patient's good and bad perceptions of drinking and the motivation and confidence to change drinking behaviours; non-confrontational; patient-centred; reflective listening; empathy; boost self-efficacy; no prescription to change drinking in particular way	RCT sub-analysis (primary trial not stated)	Driving under the influence (DUI) arrest within 3 years of discharge (documented by matching demographic information, driver¡¯s licence and social security numbers to state traffic safety data)	21.9% of control group had DUI arrest versus 11.3% of intervention group. NNT=9.4. Multivariate analysis showed that intervention was the strongest protective factor for DUI arrest (OR 0.32, CI 0.11-0.96); prior number of DUIs and age were associated with DUI post-discharge but AUDIT screening score was not	Unable to assure sufficiency of sample size; 20% eligible patients refused; no patient or investigator blinding?; randomisation procedure not described; information bias regarding DUI arrests out-of-state and possible shielding of under-age DUIs; differential timing of follow-up between patients, therefore results may underestimate true 3-year DUI rates
Bazargan-Hejazi 2005 USA	295 ED patients aged >=18 years screening positive to CAGE (score >=1); spoke English or Spanish; consented; no professional alcohol counselling within past 12 months; not in police custody; medical treatment and/or cognitive impairment not precluding interview. 151 randomised to standard care (SC), 144 to brief intervention (BI) SC: medical care plus packet of health information BI: SC plus 15-20min interview by health promotion advocate. Established rapport with patient; discussed alcohol use; explored pros and cons of use (decisional balance) using reflective listening; assessed readiness to change; and negotiated plan for change based on the patient's perception of readiness. Participants given copy of plan for change	RCT	Alcohol consumption using AUDIT (Alcohol Use Disorders Identification Test) at baseline and 3months	48% of patients in BI group vs. 38% in SC group reduced their consumption (not significant). For at-risk/moderate group (AUDIT score 7 to 18) significant intervention group improvement rate of 34% versus 13% for control group (p = 0.0099). For dependent drinkers (AUDIT score 19 to 40) non-significant intervention group improvement rate of 66% versus 60%.	Questionable validity of self-report data; selection bias as 'randomisation' not truly random (by alternative allocation) and high refusal rate (40%). Sampling period limited to 9am-6pm week days. High loss to follow-up (37%). Small sample size. Short follow-up period. Patients not blinded; investigators not blinded? Only one outcome measured
Crawford 2004 UK	599 ED patients aged >=18 years screening PAT positive; consenting; English-speaking; resident within Greater London; no contact with alcohol services; not requesting help with alcohol problems. 312 randomised to control, 287 to brief intervention Control - standard care: health information leaflet 'Think about drink' including list of national help-lines and local alcohol support agencies Intervention - standard care plus appointment with alcohol health worker (mental health nurse): 30mins; assessment and discussion of current and previous drinking; help with resolving ambivalence regarding drinking; feedback about safe amounts of drinking and suggesting range of strategies to reduce alcohol consumption	RCT	Alcohol consumption over previous 3months: PAT and Form 90-AQ at 6 months; PAT (Paddington Alcohol Test), Form 90-AQ, and Steady Pattern Grid at 12 months	At 6 months significantly lower mean weekly alcohol consumption in intervention versus control group (59.7 units vs. 83.1 units, p=0.02); non-significant difference at 12 months (57.2 vs. 70.8)	Questionable validity of self-report data; high loss to follow-up (36%); insufficient baseline data collected therefore unable to assess change in outcomes from baseline; only 29% of those referred for brief intervention attended appointment; patients not blinded; attendance at other EDs not formally assessed (relied on patient self-report)
			ED re-attendance in following year using local records	Significantly fewer ED visits in intervention vs. control group (1.2 vs. 1.7, p=0.046)
			General mental health: GHQ (General Health Questionnaire) at 6 months	No significant difference
			Health-related quality of life: EQ-5D (Euro-QoL) at 12 months	No significant difference
Longabaugh 2001 USA	539 ED patients aged >= 18 years, consenting, English-speaking, presenting with injury not resulting in admission, assessed as hazardous/harmful drinker by either 1) positive BAC 2) self-reporting alcohol consumption 6 hours prior to injury or 3) AUDIT score >= 8. Residing locally, not under arrest, no psychiatric disorder, no previous diagnosis of alcohol dependence or abuse. 188 randomised to control (SC), 182 to brief intervention (BI) and 169 to brief intervention plus booster (BIB) SC - standard care: treatment for injury by ED staff BI - by social worker/ psychologist 40-60mins; open-ended questions about patient's injury and connection to alcohol use; focus on negative effects attributable to drinking; reflective listening; positive affirmations; summaries; eliciting self-motivational statements; discussing whether or not wish to change behaviour and pros and cons of target behaviour; given plan for change BIB - BI plus booster 7-10 days later; discussion of post-discharge experiences in relation to plan; additional information about alcohol use; opportunity to reflect on and change plan	RCT	Negative consequences from drinking in past year using DrInC (Drinker's Inventory of Consequences) at 12 months	Significantly fewer negative consequences in BIB versus SC group (Mean score 2.24 vs. 2.52, p<0.005). No significant difference between BI (2.40) and SC groups	Questionable validity of self-report data; insufficient sample size; sampling period limited to Thursday to Monday 8pm to 6am; high refusal rate (41%); no p-values for baseline characteristics; Bonferroni-corrected p-values not used to test significance; patients not blinded; variable interventionist success in having patient return for booster session
			Alcohol-related injuries in past year using IBC (Injury Behaviour Checklist) at 12 months	Significantly fewer alcohol-related injuries in patients in BIB versus SC group (Mean score 0.863 vs. 0.800, p<0.04). No significant difference between BI (0.807) and SC groups. In all 3 groups, total injuries decreased significantly in year following treatment relative to year prior to treatment
			Number of heavy-drinking days in past year using AUDIT at 12 months	% heavy drinking days significantly reduced in all 3 groups from pre- to post-treatment; no significant inter-group differences
Gentilello 1999 USA	762 trauma patients aged ¡Ý18 years, consenting for follow-up; English-speaking; resident within state; screening positive for alcohol problem either by 1) BAC¡Ý100mg/dl 2) SMAST (Short Michigan Alcoholism Screening Test) score ¡Ý3 3) BAC 1-99 and SMAST 1/2 4) BAC 1-99 and GGT (Gamma glutamyl transferase) above normal 5) SMAST 1/2 and GGT above normal. 396 randomised to control and 366 to brief intervention Control - standard care Intervention - motivational interview by psychologist: 30mins; personalised feedback comparing drinking quantity and frequency to national norms; level of intoxication at admission and its relation to common effects and injury risk; negative social consequences of alcohol; negative physical consequences and level of alcohol dependence. Focus on personal responsibility for reducing drinking and risk; menu of strategies to assist change; follow-up summary letter one month later	RCT	Trauma recurrence after discharge using Trauma Registry	47% reduction in new injuries requiring either ED treatment or trauma centre readmission in intervention versus control group (p=0.07). 48% reduction in hospital readmissions in intervention vs. control group with up to 3 years follow-up	Questionable validity of self-report data; high loss to follow-up by 12 months (47% intervention group, 46% control group); not all p-values stated for baseline characteristics; only 45% of control vs. 100% of intervention group underwent baseline evaluation; unable to assure sufficiency of sample size
			Alcohol consumption using AUDIT, DIS form III-R and SADD at baseline, 6 and 12 months	Significant reduction in intake in intervention group versus control group at 12 months (21.8 unit reduction vs. 6.7, p=0.03); greatest reduction in those with intermediate SMAST scores (intervention group reduction by 21.6 versus increase of 2.3 in controls). Reduction in both groups at 6 months; controls subsequently increased intake back to baseline versus a continued decline in intervention group
Sommers MS et al. 2006 US	187 trauma centre patients aged between 18 and 45 years hospitalised with an injury after an MVC (motor vehicle crash). Hospital admission within 24 hours of injury; BAC (Blood alcohol concentration) >/= 10mg/dL; English-speaking; intact cognition; potential for discharge within 4 weeks. Excluding patients attending alcohol treatment program in past year or receiving advice from health care provider in past 3 months; evidence of alcohol withdrawal; alcohol consumption >150g /day; AUDIT (Alcohol Use Disorders Identification Test) score >/=2 56 randomised to control (C); 68 to simple advice (SA) and 63 to brief counselling (BC) C: 20-minute health interview but no intervention SA: 20-minute health interview plus 5-minute advice from nurse clinician about importance of sensible drinking or abstinence; booster repeat session at one month post-discharge plus printed self-help manual BC: 20-minute health interview plus 5-minute advice plus 15-20 minute patient-centred counselling on personal problem-solving strategies using components from TrEAT protocol and FRAMES (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) model; booster repeat session at one month post-discharge plus printed self-help manual	RCT	Alcohol consumption (standard drinks/ month and binges/ month) using Timeline Followback procedure at baseline and 12 months	Significant reduction across all groups in standard drinks / month and binges / month (mean 56.8 to 32.1 and 5.79 to 3.21 at 12 months). No significant inter-group difference	Questionable validity of self-report data regarding alcohol consumption; Insufficient sample size; excluded patients had significantly higher BAC than those who enrolled; high refusal rate (61%); randomisation procedure not described; patients not blinded; high loss to follow-up (47%) significantly higher attrition rate in Black/African patients vs. White patients (67% vs. 44% p=0.05)
			Adverse driving events (driving-related suspension, citations for driving under the influence (DUI), any citation (inc DUI) anytime during 12 months before or after the MVC but not including it) via police crash records and driving records from state motor vehicle departments	Only significant reduction in motor vehicle citations across all groups (35% vs. 26% from pre-post MVC, p=0.019). No significant inter-group difference
			Health status (number and length of hospital stays, number of ED visits and number of activity-limiting illness / injury within past 12 months) via interview	Only significant reduction in activity-limiting illness / injury within past month (37% vs. 20% at 12-month follow-up, p=0.011). No significant inter-group difference
Dauer AR et al 2006 Spain	85 trauma patients aged ¡Ý18 years; MVC within 6hr prior to admission; positive BAC (¡Ý0.2g/dL); Spanish-speaking; consenting; residents; AUDIT<15; not presenting with severe medical, psychiatric or social conditions; no alcohol dependence. 45 randomised to minimal intervention; (MI) 40 to brief intervention (BI) MI ¨C 5mins; empathic advice after comparing evaluated behaviour with advisable one; information leaflet BI ¨C 15-20mins; motivational intervention; FRAMES; discussion of good and bad things derived from alcohol consumption; striking a balance; drawing own conclusions; information leaflet and self-help booklet Both administered by nurse or social worker	RCT	Alcohol consumption during previous month using AUDIT-C at 3,6 and 12 months	47.5% of patients in BI group vs. 42% in MI group had reduced consumption at 12 months (not significant)	Questionable validity of self-report data regarding alcohol consumption; small sample size; no traditional control group; randomisation procedure not described; intention-to-treat analysis only performed at 12months; only 85 of 126 (67%) eligible patients were enrolled due to logistical reasons; high loss to follow-up (33%); source of data regarding accident rate not stated; patients not blinded
			Proportion of AUDIT-C positive patients (¡Ý5 for males, ¡Ý4 for females) becoming negative	52% of AUDIT-C positive patients in BI group versus 48% in MI group had become negative at 12 months (not significant)
			Number of accidents within previous year at baseline and 12 months	Significant 60% reduction in accident rates (p<0.05) in total sample
Mello MJ et al 2005 US	As Longabaugh et al. Patients retrospectively analysed by separating those with sub-critical injuries from motor vehicle crash (MVC) from those with non-MVC injuries. 46 in MVC-SC, 107 in non-MVC-SC; 53 MVC-BI, 95 non-MVC-BI; 34 MVC-BIB, 98 non-MVC-BIB	RCT	Negative consequences from drinking in past year using DrInC	Non-significant differences between MVC and non-MVC groups	Questionable validity of self-report data; insufficient sample size; unequal numbers of MVC and non-MVC participants as original randomisation not conducted on basis of injury type; baseline data inadequately reported; analyses inadequately reported
			Alcohol-related and total injuries in past year using IBC	MVC-BIB group had significantly fewer injuries than MVC-SC group (p<0.001). In non-MVC group, no significant differences between BIB and SC arms

Comment(s)

Variation in inclusion criteria, the content and duration of intervention and the measurement tools used limits comparison of trials. Study weaknesses reflect the difficulties of conducting RCTs in a hard-to-reach population within a busy healthcare setting: time constraints, high staff and patient turnover and emergency care requirements make recruitment difficult, demonstrable by the small samples sizes, high refusal rates and losses to follow-up; furthermore, adequate blinding is problematic. Many trials conclude that it is difficult to separate the effect on outcomes of the ED attendance itself vs. the screening process for enrolment into trials vs. the actual intervention delivered, thus adding to the complexity of interpretation

Clinical Bottom Line

Despite the difficulties faced in attempting to conduct robust trials in the ED setting, results show that brief psychotherapeutic intervention is worthwhile in adults who attend the emergency department after an alcohol-related event

References

1. Schermer CR, Moyers TB, Miller WR et al Trauma Center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests J Trauma 2006;60:29-34
2. Bazargan-Hejazi S, Bing E, Bazargan M et al Evaluation of a brief intervention in an inner-city emergency department Ann Emerg Med 2005;46:67-76
3. Crawford MJ, Patton R, Touquet R et al Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial Lancet 2004;364:1334-9
4. Longabaugh R, Woolard RE, Nirenberg TD et al Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department J Stud Alcohol 2001;62:806-16
5. Gentilello LM, Rivara FP, Donovan DM et al Alcohol interventions in a trauma centre as a means of reducing the risk of injury recurrence Ann Surg 1999;230:473-83
6. Sommers MS, Dyehouse JM, Howe SR et al. Effectiveness of brief interventions after alcohol-related vehicular injury: a randomised controlled trial J Trauma 2006;61:523-533
7. Dauer AR, Rubio ES, Coris ME et al Brief intervention in alcohol-positive traffic casualties: is it worth the effort? Alcohol Alcohol 2006;41:76-83
8. Mello MJ, Nirenberg TD, Longabaugh R et al Emergency Department brief motivational interventions for alcohol with motor vehicle crash patients Ann Emerg Med 2005;45:620-5