A systematic review of emergency care brief alcohol interventions for injury patients

Effects of brief intervention on subgroups of injured patients who drink at risk levels

Alcohol-related injuries are a major source of admission for trauma care. Screening and brief intervention (SBI) for injured patients can result in decreased drinking and risk behaviors. It is not clear SBI is equally beneficial for all injured patients. A secondary data analysis of 553 patients admitted to two Level-1 trauma centers was conducted. Latent class analysis was used to identify patient subgroups based on injury-related risks and consequences of alcohol use. Intervention effects on drinking were examined among subgroups. Five subgroups were identified. Drinking improved in patients reporting multiple risks and injuries/accidents and drinking and driving. Patients that reported drinking and driving and taking foolish risks or fighting while drinking and taking foolish risks did not show improvements. Trauma centers may benefit from targeting interventions based on injury-related risks and consequences of alcohol use. Further research is needed to test bedside approaches for tailored interventions.

Meta-analysis on the effectiveness of alcohol screening with brief interventions for patients in emergency care settings

BACKGROUND AND AIMS

Despite ambiguous evidence for the effectiveness of alcohol screening with brief interventions (BI) in emergency departments (ED), ambition for their widespread implementation continues to grow. To clarify whether such an application of BI is justifiable, we conducted a systematic review and meta-analysis on studies testing the impact of BI on alcohol consumption.

METHODS

We included peer-reviewed, randomized controlled studies investigating the effects of BI on alcohol consumption in injured and/or intoxicated patients, published January 2002-September 2015. Changes from baseline in consumption quantity, intensity and number of heavy drinking episodes were assessed at 3-, 6- and 12-month follow-up, resulting in nine separate random-effects meta-analyses of standardized mean differences (SMD). Moderation effects of intervention mode, length, type of interventionist, intensity of control intervention and study quality were assessed using subgroup comparisons and meta-regression.

RESULTS

We considered 33 publications (28 separate studies) including 14 456 patients. Six of nine comparisons revealed small significant effects in favour of BI, with the highest SMD at 0.19 [95% confidence interval (CI) = 0.08-0.31]. No significant moderators could be identified, and statistical heterogeneity (I(2) ) was below 40%.

CONCLUSIONS

In a large meta-analysis of randomized controlled trials in emergency care settings, there was evidence for very small effects of brief interventions on alcohol consumption reductions. More intensive interventions showed no benefit over shorter approaches. Non-face-to-face interventions appear to be comparably effective, but this finding remains tentative due to the low number of non-face-to-face studies.

Alcohol use disorders

Alcohol use disorders are common in developed countries, where alcohol is cheap, readily available, and heavily promoted. Common, mild disorders often remit in young adulthood, but more severe disorders can become chronic and need long-term medical and psychological management. Doctors are uniquely placed to opportunistically assess and manage alcohol use disorders, but in practice diagnosis and treatment are often delayed. Brief behavioural intervention is effective in primary care for hazardous drinkers and individuals with mild disorders. Brief interventions could also encourage early entry to treatment for people with more-severe illness who are underdiagnosed and undertreated. Sustained abstinence is the optimum outcome for severe disorder. The stigma that discourages treatment seeking needs to be reduced, and pragmatic approaches adopted for patients who initially reject abstinence as a goal. To engage people in one or more psychological and pharmacological treatments of equivalent effectiveness is more important than to advocate a specific treatment. A key research priority is to improve the diagnosis and treatment of most affected people who have comorbid mental and other drug use disorders.

Developing a framework of care for opioid medication misuse in community pharmacy

BACKGROUND

Prescription opioid misuse is a major public health concern in the US. Few resources exist to support community pharmacists engaging patients who misuse or are at risk for misuse.

OBJECTIVES

This report describes the results of the execution of the ADAPT-ITT model (a model for modifying evidence-based behavioral interventions to new populations and service settings) to guide the development of a behavioral health framework for opioid medication misuse in the community pharmacy setting.

METHODS

Pharmacy, addiction, intervention, and treatment experts were convened to attend a one-day meeting to review the empirical knowledgebase and discuss adapting the screening, brief intervention, and referral to treatment (SBIRT) protocol for addressing opioid medication misuse in community pharmacy. Qualitative data gathered from the meeting were analyzed by 2 independent coders in a 2-cycle process using objective coding schemes. Percentage of agreement and Cohen's Kappa were calculated to assess coder agreement.

RESULTS

First-cycle coding identified 4 distinct themes, with coder percentage of agreement ranging from 93.5 to 99.6% and with Kappa values between 0.81 and 0.93. Second-cycle coding identified 10 sub-themes, with coder percentage of agreement ranging from 83 to 99.8% and with Kappa values between 0.58 and 0.93. Identified themes and sub-themes encompassed patient identification, intervention, prevention, and referral to treatment.

CONCLUSIONS

Focus of screening efforts in the emerging model should capitalize on pharmacists' knowledge of medication management. Screening likewise should be multidimensional in order to facilitate patient-centered interventions that activate additional disciplines able to interface with patients at risk or involved in medication misuse.

The prevalence of alcohol-related trauma recidivism: A systematic review

OBJECTIVE

Recurrent admission to a hospital or trauma centre for separate incidents of traumatic injury is known as trauma recidivism. Although use of alcohol is a known risk factor for injury and associated with trauma recidivism, the scale of alcohol-related trauma recidivism has not been well described. The purpose of this review was to search the published literature for studies that evaluated the prevalence of alcohol use among trauma recidivists. Our primary objective was to determine the proportion of trauma recidivism related to alcohol use. The association between alcohol and trauma recidivism was evaluated as a secondary objective.

METHODS

Four electronic databases (MEDLINE, Embase, CINAHL, Web of Science) were searched from inception until December 2015 for all articles that might provide evidence on the proportion of trauma recidivism related to use of alcohol. After removal of duplicates, the search strategy yielded 2470 records for screening. Only primary studies that reported on repeated admissions to a hospital or trauma centre for traumatic injuries specifically related to alcohol use were included. Descriptive statistics were used to assess study characteristics and the prevalence of trauma recidivism related to alcohol use. An aggregate weighted estimate of alcohol-related trauma recidivism was calculated.

RESULTS

A total of 12 studies met all inclusion criteria. Studies were published between 1989 and 2014. Overall, there were 3386 trauma recidivists among included studies. The proportion of trauma recidivists with evidence of alcohol use on admission ranged from 26.7% to 76.9% (median 46.4%). The aggregated sample produced a weighted estimate of 41.0% (1388/3386) for alcohol-related trauma recidivism. In four studies, the association between alcohol and trauma recidivism was examined; all four found a positive association between alcohol use and repeated admission for traumatic injury. Studies varied considerably in design, trauma populations, periods for evaluating recidivism, definitions for positive alcohol on admission, and methods used to determine alcohol use.

CONCLUSION

Evidence from current literature suggests that 41.0% of trauma recidivism is related to use of alcohol. Due to methodological limitations among the studies included for review, this may underestimate the actual prevalence of alcohol-related trauma recidivism.

A Randomized Controlled Trial of a Telephone Intervention for Alcohol Misuse With Injured Emergency Department Patients

STUDY OBJECTIVE

We conduct a randomized controlled trial to test efficacy of a telephone intervention for injured emergency department (ED) patients with alcohol misuse to decrease alcohol use, impaired driving, alcohol-related injuries, and alcohol-related negative consequences.

METHODS

ED patients screening positive for alcohol misuse were randomized to a 3-session telephone brief motivational intervention on alcohol, delivered by a counselor trained in motivational interviewing during 6 weeks, or a control intervention of a scripted home fire and burn safety education delivered in 3 calls. Patients were followed for 12 months and assessed for changes in alcohol use, impaired driving, alcohol-related injuries, and alcohol-related negative consequences.

RESULTS

Seven hundred thirty ED patients were randomized; 78% received their assigned intervention by telephone, and of those, 72% completed 12-month assessments. There were no differential benefits of telephone brief motivational intervention versus assessment and a control intervention in all 3 variables of alcohol use (frequency of binge alcohol use during the previous 30 days, maximum number of drinks at one time in the past 30 days, and typical alcohol use in the past 30 days), alcohol-impaired driving, alcohol-related injuries, and alcohol-related negative consequences.

CONCLUSION

Despite the potential advantage of delivering a telephone brief motivational intervention in not disrupting ED clinical care, our study found no efficacy for it over an assessment and control intervention. Potential causes for our finding include that injury itself, alcohol assessments, or the control intervention had active ingredients for alcohol change.

Evaluation of a brief intervention to reduce the negative consequences of drug misuse among adult emergency department patients

OBJECTIVES

Determine if a brief intervention (BI) reduces the negative consequences of drug use/misuse among adult emergency department (ED) patients, and identify patients more likely to benefit from the BI.

METHODS

This randomized, controlled trial enrolled 1026 18-64 year-old ED patients whose drug misuse indicated a needed for a BI. Differences in total Inventory of Drug Use Consequences (InDUC) scores between the treatment (BI) and control arms (no BI) were assessed every 90 days over a one-year period. Regression models were constructed to identify demographic and clinical factors associated with greater reductions in total InDUC scores.

RESULTS

Although total InDUC scores decreased for both the treatment and control arms, there were no differences in scores between the treatment and the control arms at baseline at each follow-up. In the regression analyses, participants who were not using drugs or received drug treatment in the past 90 days generally had lower InDUC scores at each follow-up.

CONCLUSIONS

Although negative consequences decreased in both study arms over time, receiving a BI did not lead to a greater reduction in the negative consequences of drug misuse than not receiving a BI. Of importance in the design of future ED drug misuse interventions, participants who were successful in stopping their drug misuse or receiving drug treatment did show fewer negative consequences of drug use/misuse.

Does Brief Intervention Work For Heavy Episodic Drinking? A Comparison of Emergency Department Patients in Two Cultures

Little has been reported on the efficacy of brief intervention (BI) among heavy episodic drinkers, although this drinking style is known to be especially harmful in relation to negative consequences including alcohol-related injuries. The comparative efficacy of BI is analyzed in two similar randomized controlled clinical trials of emergency department (ED) patients in two different cultures, both of which exhibit similar drinking styles of heavy episodic drinking: Poland and Mexican-Americans in the U.S. Improvements in drinking and problem outcomes are analyzed at 3-month and 12-month follow-up, using random effects modeling, among 446 Polish patients and 698 Mexican-American patients, randomized to screened only, assessment, and intervention conditions in each study. In Poland significant improvement was observed in all outcome measures for the assessed condition at 3-months compared to baseline, but only in the two problem variables at 12-months, while for the intervention condition, significant improvement was found in all outcome measures at both time periods; however, estimates of the interaction terms were not statistically significant. In the Mexica-American study, while significant improvement in nearly all outcome measures were observed at 3 months and 12 months for both conditions, estimates of the interaction terms suggest that for all drinking variables, but not problem variables, outcomes were significantly improved for the intervention condition over the assessed condition at 12 months, suggesting a 12-month intervention effect. Findings here are non-conclusive regarding a treatment effect of BI for heavy episodic drinking in ED patients. Given the mixed findings for BI in other ED studies, future studies need to explore the efficacy of BI in other populations and cultures exhibiting different drinking patterns to help identify what type of drinker would most benefit from BI in the ED setting.

Development of a text message intervention aimed at reducing alcohol-related harm in patients admitted to hospital as a result of injury

Background

Screening for alcohol misuse and brief interventions (BIs) for harm in trauma care settings are known to reduce alcohol intake and injury recidivism, but are rarely implemented. We created the content for a mobile phone text message BI service to reduce harmful drinking among patients admitted to hospital following an injury who screen positive for hazardous alcohol use. The aim of this study was to pre-test and refine the text message content using a robust contextualisation process ahead of its formal evaluation in a randomised controlled trial.

Methods

Pre-testing was conducted in two phases. First, in-depth interviews were conducted with 14 trauma inpatients (16–60 years) at Auckland City Hospital and five key informants. Participants were interviewed face-to-face using a semi-structured interview guide. Topics explored included: opinions on text message ideas and wording, which messages did or did not work well and why, interactivity of the intervention, cultural relevance of messages, and tone of the content. In a second phase, consultation was undertaken with Māori (New Zealand’s indigenous population) and Pacific groups to explore the relevance and appropriateness of the text message content for Māori and Pacific audiences.

Results

Factors identified as important for ensuring the text message content was engaging, relevant, and useful for recipients were: reducing the complexity of message content and structure; increasing the interactive functionality of the text message programme; ensuring an empowering tone to text messages; and optimising the appropriateness and relevance of text messages for Māori and Pacific people. The final version of the intervention (named ‘YourCall^™’) had three pathways for people to choose between: 1) text messages in English with Te Reo (Māori language) words of welcome and encouragement, 2) text messages in Te Reo Māori, and 3) text messages in English (with an option to receive a greeting in Samoan, Tongan, Cook Island Māori, Niuean, Tokelauan, Tuvaluan, or Fijian).

Conclusions

We have developed a text message intervention underpinned by established BI evidence and behaviour change theory and refined based on feedback and consultation. The next step is evaluation of the intervention in a randomised-controlled trial.

The Impact of a Mandated Trauma Center Alcohol Intervention on Readmission and Cost per Readmission in Arizona

BACKGROUND

Persons appearing in trauma centers have a higher prevalence of unhealthy alcohol use than the general population. Screening and brief intervention (SBI) is designed to moderate drinking levels and avoid costly future readmissions, but few studies have examined the impact of SBI on hospital readmissions and health care costs in a trauma population.

RESEARCH DESIGN

This study uses comparative interrupted time-series and the Arizona State Inpatient Database to estimate the effect of the American College of Surgeons Committee on Trauma SBI mandate on the probability of readmission and cost per readmission in Arizona trauma centers. We compare individuals with and without an alcohol diagnosis code before and after the mandate was implemented.

RESULTS

The mandate resulted in a 2.2 percentage point reduction (44%) in the probability of readmission. Total health care and readmission costs were not affected by the mandate.

CONCLUSIONS

The estimates are consistent with a differential effect of SBI: SBI reduces readmissions among those who present with a less serious alcohol-related problem. Persons with more serious alcohol problems are less likely to respond to SBI. These higher risk individuals likely have a higher cost, which may explain the lack of change in readmission costs. Our study is a macrolevel intent-to-treat analysis of SBI's impact that corroborates the potential of SBI implied by efficacy studies in trauma centers and other settings. This study provides a framework for future research involving more states and health systems and evaluating other SBI policies.

Brief Intervention in the Emergency Department Among Mexican-Origin Young Adults at the US-Mexico Border: Outcomes of a Randomized Controlled Clinical Trial Using Promotores

AIMS

A randomized controlled trial of brief intervention (BI), for drinking and related problems, using peer health promotion advocates (promotores), was conducted among at-risk and alcohol-dependent Mexican-origin young adult emergency department (ED) patients, aged 18-30.

METHODS

Six hundred and ninety-eight patients were randomized to: screened only (n = 78), assessed (n = 310) and intervention (n = 310). Primary outcomes were at-risk drinking and Rapid Alcohol Problems Screen (RAPS4) scores. Secondary outcomes were drinking days per week, drinks per drinking day, maximum drinks in a day and negative consequences of drinking.

RESULTS

At 3- and 12-month follow-up the intervention condition showed significantly lower values or trends on all outcome variables compared to the assessed condition, with the exception of the RAPS4 score; e.g. at-risk drinking days dropped from 2.9 to 1.7 at 3 months for the assessed condition and from 3.2 to 1.2 for the intervention condition. Using random effects modeling controlling for demographics and baseline values, the intervention condition showed significantly greater improvement in all consumption measures at 12 months, but not in the RAPS4 or negative consequences of drinking. Improvements in outcomes were significantly more evident for non-injured patients, those reporting drinking prior to the event, and those lower on risk taking disposition.

CONCLUSIONS

At 12-month follow-up this study demonstrated significantly improved drinking outcomes for Mexican-origin young adults in the ED who received a BI delivered by promotores compared to those who did not.

TRIAL REGISTER

ClinicalTrials.gov.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02056535.

A comparison of the efficacy of brief interventions to reduce hazardous and harmful alcohol consumption between European and non-European countries: a systematic review and meta-analysis of randomized controlled trials

AIMS

The extent of variation attributable to regional differences for the efficacy of brief intervention (BI) to reduce hazardous and harmful alcohol consumption is unclear. The primary aim of this study was to determine overall efficacy of BI at 6- and 12-month follow-up in primary health care (PHC) and emergency department (ED) studies. The secondary aim was to examine whether variance in study outcome can be explained by the geographical region in which trials have taken place (European versus non-European).

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) published before August 2014 was undertaken. Twenty RCTs conducted in PHC settings with a total of 8226 participants (European = 4564/non-European = 3662) and eight RCTs conducted in ED settings with a total of 4799 participants (European = 2465/non-European = 2334) were eligible. Primary outcome measure was reduction in grams of alcohol consumed per week for BI and control groups at 6- and 12-month follow-up. An inverse variance model was applied to measure the effect of treatment in mean differences for BI and control groups at 6- and 12-month follow-up. Variance between study outcomes was explored using subgroup analysis of European versus non-European countries.

RESULTS

For PHC trials at 6-month follow-up, statistically significant benefits of BI were indicated [mean difference (MD) = -21.98 g/week; 95% confidence interval (CI) = -37.40 to -6.57; P = 0.005]. At 12-month follow-up, statistically significant benefit of BI was evident (MD = -30.86 g/week; 95% CI = -46.49 to -15.23; P = 0.0001). For ED trials at 6-month follow-up, statistically significant benefits of BI were indicated (MD = -17.97 g/week; 95% CI = -29.69 to -6.24; P =  .003). At 12-month follow-up, statistically significant benefit in favour of BI was evident (MD = -18.21 g/week; 95% CI = -26.71 to -9.70; P < 0.0001). No statistically significant differences were detected in subgroup analyses of outcomes for European versus non-European studies.

CONCLUSIONS

Brief intervention (BI) to reduce alcohol consumption is associated with reducing grams of alcohol consumed per week among hazardous and harmful drinkers at 6- and 12-month follow-up in primary health care and emergency department trials. The geographical region in which trials are undertaken does not appear to explain the variance in trial outcomes for reducing alcohol consumption.

A Randomized Evaluation of Motivational Interviewing Training for Mandated Implementation of Alcohol Screening and Brief Intervention in Trauma Centers

The American College of Surgeons has mandated that level I and level II trauma centers implement universal alcohol screening and brief intervention (SBI) for injured patients. This study was a secondary analysis of a national, 20-hospital, cluster-randomized implementation trial focusing on practical issues of training and supervising alcohol SBI providers in motivational interviewing (MI). The purpose of this study was to examine whether real-world trauma center providers can be trained to provide higher quality counseling using MI as part of brief interventions for alcohol and whether MI skills can be maintained over time. Sites were randomly assigned to receive a 1day workshop training in MI for alcohol SBI or not, and all providers regardless of training completed up to seven standardized patient assessments of MI fidelity over 27months. Six domains on the Motivational Interviewing Treatment Integrity (MITI) coding system were assessed and compared to proficiency criteria. Providers in the intervention training group showed substantially improved MITI scores over the course of the 27-month time period. Domains that had particularly strong improvement were MI spirit and empathy; however, despite the overall improvement in the intervention group scores, expert-derived proficiency criteria were attained only for the global scores. Routine trauma center providers who receive MI training can deliver higher quality counseling in alcohol brief interventions, but may not, however, attain previously derived proficiency standards. Future implementation efforts in real-world acute care medical settings could further elucidate provider characteristics that predict training response and also strive to demonstrate that higher quality alcohol SBI implementation is associated with improved patient-level outcomes.

A realist review of brief interventions for alcohol misuse delivered in emergency departments

BACKGROUND

Brief interventions (BIs) involve screening for alcohol misuse and providing feedback to patients about their use, with the aim of reducing alcohol consumption and related consequences. BIs have been implemented in various healthcare settings, including emergency departments (ED), where they have been found to contribute mixed results in their ability to address alcohol misuse among adults. Mechanisms through which BIs work and contextual factors impacting BI effectiveness are not clear. The purpose of this review was to understand how, for whom, and under what circumstances BIs work for adults misusing alcohol and who have been admitted to an ED. A realist review was chosen to answer these questions as realist reviews create context-mechanism-outcome configurations, leading to the development of comprehensive and detailed theories; in this case explaining how and for whom BIs work.

METHODS

Databases including PsycINFO, Healthstar, CINAHL, Medline, and Nursing and Allied Health were searched for articles published until December 2013. The search strategy focused on studies examining BIs that targeted alcohol misuse among adults admitted into the ED. The search identified 145 relevant abstracts, of which 36 were included in the review. The literature was synthesized qualitatively (immersion/crystallization).

RESULTS

Four mechanisms were found within reviewed studies, including engagement in/retention of BI materials, resolving ambivalence, increased awareness/insight into consequences of drinking, and increased self-efficacy/empowerment to use skills for change. The following contexts were found to impact mechanisms: emotional state, injury attributed to alcohol use, severity of alcohol use, and baseline stage of change.

CONCLUSIONS

This realist review provides advances in theories regarding which mechanisms to target during a BI and which contexts create the most favorable conditions for these mechanisms to occur, ultimately leading to optimal BI outcomes. These results can inform future clinical decision-making when delivering BIs in ED settings. Future research should conduct quantitative examination to confirm these findings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013006549.

Large-scale implementation of alcohol brief interventions in new settings in Scotland: a qualitative interview study of a national programme

Background

This study aimed to explore experiences of implementation of alcohol brief interventions (ABIs) in settings outside of primary healthcare in the Scottish national programme. The focus of the study was on strategies and learning to support ABI implementation in settings outside of primary healthcare in general, rather on issues specific to any single setting.

Methods

14 semi-structured telephone interviews were conducted with senior implementation leaders in antenatal, accident and emergency and wider settings and audio-recorded. Interviews were analysed inductively.

Results

The process of achieving large-scale, routine implementation of ABI proved challenging for all involved across the settings. Interviewees reported their experiences and identified five main strategies as helpful for strategic implementation efforts in any setting: (1) Having a high-profile target for the number of ABIs delivered in a specific time period with clarity about whose responsibility it was to implement the target; (2) Gaining support from senior staff from the start; (3) Adapting the intervention, using a pragmatic, collaborative approach, to fit with current practice; (4) Establishing practical and robust recording, monitoring and reporting systems for intervention delivery, prior to widespread implementation; and (5) Establishing close working relationships with frontline staff including flexible approaches to training and readily available support.

Conclusions

This qualitative study suggests that even with significant national support, funding and a specific delivery target, ABI implementation in new settings is not straightforward. Those responsible for planning similar initiatives should critically consider the relevance and value of the five implementation strategies identified.

A pilot feasibility trial of alcohol screening and brief intervention in the police custody setting (ACCEPT): study protocol for a cluster randomised controlled trial

Background

There is evidence of an association between alcohol use and offending behaviour and around a quarter of police time is spent on alcohol-related incidents. Police custody, therefore, provides an important opportunity to intervene. This pilot trial aims to investigate whether a definitive evaluation of screening and brief interventions aimed at reducing risky drinking in arrestees is acceptable and feasible in the custody suite setting.

Methods

Screening will be carried out by trained detention officers or drug and alcohol workers in four police forces across two geographical areas (North East and South West England). Detention officers (or drug and alcohol workers) will be cluster randomised to one of three conditions: screening only (control group), screening followed immediately by 10 min of manualised brief structured advice delivered by the individual responsible for screening (intervention 1) or screening followed by 10 min of manualised brief structured advice delivered by the individual responsible for screening plus the offer of a subsequent 20-min session of behaviour change counselling delivered by a trained alcohol health worker (intervention 2). Participants will be arrestees aged 18+ who screen positive on the Alcohol Use Disorders Identification Test. Participants will be followed up at 6 and 12 months post-intervention. An embedded qualitative process evaluation will explore acceptability of alcohol screening and brief intervention to staff and arrestees as well as facilitators and barriers to the delivery of such approaches in this setting.

Results

Recruitment is currently underway and due to end May 2015.

Conclusion

Results from this pilot trial will determine if a definitive evaluation is possible in the future and will provide stakeholder input to its design.

Trial registration

Reference number: ISRCTN89291046.

Lessons learned for follow-up phone booster counseling calls with substance abusing emergency department patients

BACKGROUND

Post-visit "booster" sessions have been recommended to augment the impact of brief interventions delivered in the emergency department (ED). This paper, which focuses on implementation issues, presents descriptive information and interventionists' qualitative perspectives on providing brief interventions over the phone, challenges, "lessons learned", and recommendations for others attempting to implement adjunctive booster calls.

METHOD

Attempts were made to complete two 20-minute telephone "booster" calls within a week following a patient's ED discharge with 425 patients who screened positive for and had recent problematic substance use other than alcohol or nicotine.

RESULTS

Over half (56.2%) of participants completed the initial call; 66.9% of those who received the initial call also completed the second call. Median number of attempts to successfully contact participants for the first and second calls were 4 and 3, respectively. Each completed call lasted an average of about 22 minutes. Common challenges/barriers identified by booster callers included unstable housing, limited phone access, unavailability due to additional treatment, lack of compensation for booster calls, and booster calls coming from an area code different than the participants' locale and from someone other than ED staff.

CONCLUSIONS

Specific recommendations are presented with respect to implementing a successful centralized adjunctive booster call system. Future use of booster calls might be informed by research on contingency management (e.g., incentivizing call completions), smoking cessation quitlines, and phone-based continuing care for substance abuse patients. Future research needs to evaluate the incremental benefit of adjunctive booster calls on outcomes over and above that of brief motivational interventions delivered in the ED setting.

Screening and brief intervention for substance misuse: Does it reduce aggression and HIV-related risk behaviours?

PURPOSE

To explore whether reducing substance misuse through a brief motivational intervention also reduces aggression and HIV risk behaviours.

METHODS

Participants were enrolled in a randomized controlled trial in primary care if they screened positive for substance misuse. Substance misuse was assessed using the Alcohol, Smoking and Substance Involvement Screening Test; aggression, using a modified version of the Explicit Aggression Scale; and HIV risk, through a count of common risk behaviours. The intervention was received on the day of the baseline interview, with a 3-month follow-up.

RESULTS

Participants who received the intervention were significantly more likely to reduce their alcohol use than those who did not; no effect was identified for other substances. In addition, participants who reduced substance misuse (whether as an effect of the intervention or not) also reduced aggression but not HIV risk behaviours.

CONCLUSIONS

Reducing substance misuse through any means reduces aggression; other interventions are needed for HIV risk reduction.

The Cost-effectiveness of Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Emergency and Outpatient Medical Settings

OBJECTIVE

This study analyzed the cost-effectiveness of delivering alcohol screening, brief intervention, and referral to treatment (SBIRT) in emergency departments (ED) when compared to outpatient medical settings.

METHODS

A probabilistic decision analytic tree categorized patients into health states. Utility weights and social costs were assigned to each health state. Health outcome measures were the proportion of patients not drinking above threshold levels at follow-up, the proportion of patients transitioning from above threshold levels at baseline to abstinent or below threshold levels at follow-up, and the quality-adjusted life years (QALYs) gained. Expected costs under a provider perspective were the marginal costs of SBIRT, and under a societal perspective were the sum of SBIRT cost per patient and the change in social costs. Incremental cost-effectiveness ratios were computed.

RESULTS

When considering provider costs only, compared to outpatient, SBIRT in ED cost $8.63 less, generated 0.005 more QALYs per patient, and resulted in 13.8% more patients drinking below threshold levels. Sensitivity analyses in which patients were assumed to receive a fixed number of treatment sessions that met clinical sites' guidelines made SBIRT more expensive in ED than outpatient; the ED remained more effective. In this sensitivity analysis, the ED was the most cost-effective setting if decision makers were willing to pay more than $1500 per QALY gained.

CONCLUSIONS

Alcohol SBIRT generates costs savings and improves health in both ED and outpatient settings. EDs provide better effectiveness at a lower cost and greater social cost reductions than outpatient.

Can motivational interviewing in emergency care reduce alcohol consumption in young people? A systematic review and meta-analysis

AIMS

We investigate the effect of motivational interviewing (MI), delivered in a brief intervention during an emergency care contact, on the alcohol consumption of young people who screen positively for present or previous risky alcohol consumption.

METHODS

MEDLINE, CINAHL, EMBASE, PsycARTICLES, PsycINFO, PSYNDEX and Scopus were searched for randomized controlled trials with adolescents or young adults that compared MI in an emergency care setting to control conditions and measured drinking outcomes.

RESULTS

Six trials with 1433 participants, aged 13-25 years, were included in the systematic review and meta-analysis. MI was never less efficacious than a control intervention. Two trials found significantly more reduction in one or more measures of alcohol consumption in the MI intervention group. One trial indicated that MI may be used most effectively in young people with high-volume alcohol consumption. Separate random effects meta-analyses were performed based on the highest impact that MI added on reducing the drinking frequency and the drinking quantity at any point in time during the different study periods. Their results were expressed as standardized mean differences (SMDs). The frequency of drinking alcohol decreased significantly more after MI than after control interventions (SMD ≤ -0.17, P ≤ 0.03). In addition, MI reduced the drinking quantity further than control interventions in a meta-analysis of the subset of trials that were implemented in the USA (SMD = -0.12, P = 0.04). Meta-analyses of the smallest mean differences between MI and control groups detected no differences in alcohol use (SMD ≤ 0.02, P ≥ 0.38).

CONCLUSION

MI appears at least as effective and may possibly be more effective than other brief interventions in emergency care to reduce alcohol consumption in young people.

Latent Classes Among Recipients of a Brief Alcohol Intervention: A Replication Analysis

The purpose of this study was to identify differential improvement in alcohol use among injured patients following brief intervention. Latent class analysis was conducted to identify patient profiles based on alcohol-related risk from two clinical trials (Texas: N = 737; Maryland: N = 250) conducted in Level-1 trauma centers. Drinking was analyzed to detect improvements at 6 and 12 months. The four classes that emerged from Maryland participants were similar to four of the five classes from Texas. Increases in both studies for days abstinent were reported by classes characterized by multiple risks and minimal risks. Decreases in volume consumed for both studies were also reported by classes characterized by multiple risks and minimal risks. By classifying patients according to alcohol-related risk, providers may be able to build on positive prognoses for drinking improvements or adapt interventions to better serve those likely to improve less.

A research agenda for gender and substance use disorders in the emergency department

For many years, gender differences have been recognized as important factors in the etiology, pathophysiology, comorbidities, and treatment needs and outcomes associated with the use of alcohol, drugs, and tobacco. However, little is known about how these gender-specific differences affect ED utilization; responses to ED-based interventions; needs for substance use treatment and barriers to accessing care among patients in the ED; or outcomes after an alcohol-, drug-, or tobacco-related visit. As part of the 2014 Academic Emergency Medicine consensus conference on "Gender-Specific Research in Emergency Care: Investigate, Understand and Translate How Gender Affects Patient Outcomes," a breakout group convened to generate a research agenda on priority questions related to substance use disorders.

Alcohol screening and brief intervention in workplace settings and social services: a comparison of literature

BACKGROUND

The robust evidence base for the effectiveness of alcohol screening and brief interventions (ASBIs) in primary health care (PHC) suggests that a widespread expansion of ASBI in non-medical settings could be beneficial. Social service and criminal justice settings work frequently with persons with alcohol use disorders, and workplace settings can be an appropriate setting for the implementation of alcohol prevention programs, as a considerable part of their social interactions takes place in this context.

METHODS

Update of two systematic reviews on ASBI effectiveness in workplaces, social service, and criminal justice settings. Review to identify implementation barriers and facilitators and future research needs of ASBI in non-medical settings.

RESULTS

We found a limited number of randomized controlled trials in non-medical settings with an equivocal evidence of effectiveness of ASBI. In terms of barriers and facilitators to implementation, the heterogeneity of non-medical settings makes it challenging to draw overarching conclusions. In the workplace, employee concerns with regard to the consequences of self-disclosure appear to be key. For social services, the complexity of certain client needs suggest that a stepped and carefully tailored approach is likely to be required.

DISCUSSION

Compared to PHC, the reviewed settings are far more heterogeneous in terms of client groups, external conditions, and the focus on substance use disorders. Thus, future research should try to systematize these differences, and consider their implications for the deliverability, acceptance, and potential effectiveness of ASBI for different target groups, organizational frameworks, and professionals.

Components of Brief Alcohol Interventions for Youth in the Emergency Department

BACKGROUND

Alcohol brief interventions (BIs) delivered by therapists are promising among underage drinkers in the emergency department (ED); however, integration into routine ED care is lacking. Harnessing technology for identification of at-risk drinkers and delivery of interventions could have tremendous public health impact by addressing practical barriers to implementation. The paper presents baseline, within BI session, and posttest data from an ongoing randomized controlled trial (RCT) of youth in the ED.

METHODS

Patients (ages 14-20) who screened positive for risky drinking were randomized to computer BI (CBI), therapist BI (TBI), or control. Measures included demographics, alcohol consumption (Alcohol Use Disorders Identification Test--Consumption [AUDIT-C]), process questions, BI components (e.g., strengths, tools), and psychological constructs (i.e., importance of cutting down, likelihood of cutting down, readiness to stop, and wanting help).

RESULTS

Among 4389 youth surveyed (13.7% refused), 24.0% (n = 1053) screened positive for risky drinking and 80.3% (n = 836) were enrolled in the RCT; 93.7% (n = 783) completed the posttest. Although similar in content, the TBI included a tailored, computerized workbook to structure the session, whereas the CBI was a stand-alone, offline, Facebook-styled program. As compared with controls, significant increases were found at posttest for the TBI in "importance to cut down" and "readiness to stop" and for the CBI in "importance and likelihood to cut down." BI components positively associated with outcomes at posttest included greater identification of personal strengths, protective behavioral strategies, benefits of change, and alternative activities involving sports. In contrast, providing information during the TBI was negatively related to outcomes at posttest.

CONCLUSIONS

Initial data suggest that therapist and computer BIs are promising, increasing perceived importance of reducing drinking. In addition, findings provide clues to potentially beneficial components of BIs. Future studies are needed to identify BI components that have the greatest influence on reducing risky drinking behaviors among adolescents and emerging adults.

Individual versus significant-other-enhanced brief motivational intervention for alcohol in emergency care

OBJECTIVE

Effects of brief motivational interventions (BMIs) for heavy drinkers identified by alcohol-related emergency department (ED) visits are mixed. The successes of including significant others (SOs) in behavioral treatment suggest that involving SOs in ED-delivered BMI might prove beneficial. This study investigated the relative efficacy of an SO-enhanced motivational intervention (SOMI) compared with an individual motivational intervention (IMI) to address heavy drinking in emergency care settings.

METHOD

ED (n = 317) or trauma unit (n = 89) patients were randomly assigned to receive either an IMI or an SOMI and were reassessed at 6 and 12 months for alcohol consumption, alcohol-related consequences, and perceived alcohol-specific SO support.

RESULTS

Generalized estimating equation analyses showed consistent reductions over time for both alcohol consumption and consequences. At 1-year follow-up, the average reduction in total drinks consumed per week was greater for patients in the SOMI condition than the IMI condition. In SOMI, 9.4% more patients moved to within the national guidelines for weekly drinking than did IMI patients. Frequency of heavy drinking and negative alcohol consequences showed no differential effects of intervention.

CONCLUSIONS

Emergence of a modest treatment effect at 12 months suggests that SO involvement in the SOMI condition may have led to more sustained positive influence on patient drinking than in the IMI condition. Implications and limitations regarding SO involvement in brief treatment are discussed.

The Quik Fix study: a randomised controlled trial of brief interventions for young people with alcohol-related injuries and illnesses accessing emergency department and crisis support care

Background

Alcohol is a major preventable cause of injury, disability and death in young people. Large numbers of young people with alcohol-related injuries and medical conditions present to hospital emergency departments (EDs). Access to brief, efficacious, accessible and cost effective treatment is an international health priority within this age group. While there is growing evidence for the efficacy of brief motivational interviewing (MI) for reducing alcohol use in young people, there is significant scope to increase its impact, and determine if it is the most efficacious and cost effective type of brief intervention available. The efficacy of personality-targeted interventions (PIs) for alcohol misuse delivered individually to young people is yet to be determined or compared to MI, despite growing evidence for school-based PIs. This study protocol describes a randomized controlled trial comparing the efficacy and cost-effectiveness of telephone-delivered MI, PI and an Assessment Feedback/Information (AF/I) only control for reducing alcohol use and related harm in young people.

Methods/design

Participants will be 390 young people aged 16 to 25 years presenting to a crisis support service or ED with alcohol-related injuries and illnesses (including severe alcohol intoxication). This single blinded superiority trial randomized young people to (i) 2 sessions of MI; (ii) 2 sessions of a new PI or (iii) a 1 session AF/I only control. Participants are reassessed at 1, 3, 6 and 12 months on the primary outcomes of alcohol use and related problems and secondary outcomes of mental health symptoms, functioning, severity of problematic alcohol use, alcohol injuries, alcohol-related knowledge, coping self-efficacy to resist using alcohol, and cost effectiveness.

Discussion

This study will identify the most efficacious and cost-effective telephone-delivered brief intervention for reducing alcohol misuse and related problems in young people presenting to crisis support services or EDs. We expect efficacy will be greatest for PI, followed by MI, and then AF/I at 1, 3, 6 and 12 months on the primary and secondary outcome variables. Telephone-delivered brief interventions could provide a youth-friendly, accessible, efficacious, cost-effective and easily disseminated treatment for addressing the significant public health issue of alcohol misuse and related harm in young people.

Trial registration

This trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN12613000108718.

Impact of gender on patient preferences for technology-based behavioral interventions

Introduction:

Technology-based interventions offer an opportunity to address high-risk behaviors in the emergency department (ED). Prior studies suggest behavioral health strategies are more effective when gender differences are considered. However, the role of gender in ED patient preferences for technology-based interventions has not been examined. The objective was to assess whether patient preferences for technology-based interventions varies by gender.

Methods:

This was a secondary analysis of data from a systematic survey of adult (≥18 years of age), English-speaking patients in a large urban academic ED. Subjects were randomly selected during a purposive sample of shifts. The iPad survey included questions on access to technology, preferences for receiving health information, and demographics. We defined “technology-based” as web, text message, e-mail, social networking, or DVD; “non-technology-based” was defined as in-person, written materials, or landline. We calculated descriptive statistics and used univariate tests to compare men and women. Gender-stratified multivariable logistic regression models were used to examine associations between other demographic factors (age, race, ethnicity, income) and technology-based preferences for information on specific risky behaviors.

Results:

Of 417 participants, 45.1% were male. There were no significant demographic differences between men and women. Women were more likely to use computers (90.8% versus 81.9%; p=0.03), Internet (66.8% versus 59.0%; p=0.03), and social networks (53.3% versus 42.6%; p=0.01). 89% of men and 90% of women preferred technology-based formats for at least type of health information; interest in technology-based for individual health topics did not vary by gender. Concern about confidentiality was the most common barrier to technology-based use for both genders. Multivariate analysis showed that for smoking, depression, drug/alcohol use, and injury prevention, gender modified the relationship between other demographic factors and preference for technology-based health information; e.g., older age decreases interest in technology-based information for smoking cessation in women but not in men (aOR 0.96, 95% CI 0.93-0.99 versus aOR 1.00, 95% CI 0.97-1.03).

Conclusion:

Our findings suggest ED patients' gender may affect technology preferences. Receptivity to technology-based interventions may be a complex interaction between gender and other demographic factors. Considering gender may help target ED patient populations most likely to be receptive to technology-based interventions.

Brief motivational intervention for adolescents treated in emergency departments for acute alcohol intoxication - a randomized-controlled trial

Background

Alcohol misuse among youth is a major public health concern and numbers of adolescents admitted to the emergency department for acute alcoholic intoxication in Germany are recently growing. The emergency setting offers an opportunity to reach at-risk alcohol consuming adolescents and provide brief interventions in a potential “teachable moment”. However, studies on brief interventions targeting adolescents in emergency care are scarce and little is known about their effectiveness when delivered immediately following hospitalization for acute alcohol intoxication. In this protocol we present the HaLT-Hamburg trial evaluating a brief motivational intervention for adolescents treated in the emergency department after an episode of acute alcoholic intoxication.

Methods

The trial design is a parallel two-arm cluster randomized-controlled trial with follow-up assessment after 3 and 6 months. N = 312 participants aged 17 years and younger will be recruited Fridays to Sundays in 6 pediatric clinics over a period of 30 months. Intervention condition is a manual-based brief motivational intervention with a telephone booster after 6 weeks and a manual-guided intervention for caregivers which will be compared to treatment as usual. Primary outcomes are reduction in binge drinking episodes, quantity of alcohol use on a typical drinking day and alcohol-related problems. Secondary outcome is further treatment seeking. Linear mixed models adjusted for baseline differences will be conducted according to intention-to-treat (ITT) and completers (per-protocol) principles to examine intervention effects. We also examine quantitative and qualitative process data on feasibility, intervention delivery, implementation and receipt from intervention providers, receivers and regular emergency department staff.

Discussion

The study has a number of strengths. First, a rigorous evaluation of HaLT-Hamburg is timely because variations of the HaLT project are widely used in Germany. Second, prior research has not targeted adolescents in the presumed teachable moment following acute alcohol intoxication. Third, we included a comprehensive process evaluation to raise external validity. Fourth, the study involved important stakeholders from the start to set up organizational structures for implementation and maintaining project impact.

Trial registration

Current Controlled Trials ISRCTN31234060 (April 30^th 2012).

A multisite randomized controlled trial of brief intervention to reduce drinking in the trauma care setting: how brief is brief?

OBJECTIVE

Determine the efficacy of 3 brief intervention strategies that address heavy drinking among injured patients.

BACKGROUND

The content or structure of brief interventions most effective at reducing alcohol misuse after traumatic injury is not known.

METHODS

Injured patients from 3 trauma centers were screened for heavy drinking and randomly assigned to brief advice (n = 200), brief motivational intervention (BMI) (n = 203), or BMI plus a telephone booster using personalized feedback or BMI + B (n = 193). Among those randomly assigned, 57% met criteria for moderate to severe alcohol problems. The primary drinking outcomes were assessed at 3, 6, and 12 months.

RESULTS

Compared with brief advice and BMI, BMI + B showed significant reductions in the number of standard drinks consumed per week at 3 (Δ adjusted means: -1.22, 95% confidence interval [CI]: -0.99, approximately -1.49, P = 0.01) and 6 months (Δ adjusted means: -1.42, 95% CI: -1.14, approximately -1.76, P = 0.02), percent days of heavy drinking at 6 months (Δ adjusted means: -5.90, 95% CI: -11.40, approximately -0.40, P = 0.04), maximum number of standard drinks consumed in 1 day at 3 (Δ adjusted means: -1.38, 95% CI: -1.18, approximately -1.62, P = 0.003) and 12 months (Δ adjusted means: -1.71, 95% CI: -1.47, approximately -1.99, P = 0.02), and number of standard drinks consumed per drinking day at 3 (Δ adjusted means: -1.49, 95% CI: -1.35, approximately -1.65, P = 0.002) and 6 months (Δ adjusted means: -1.28, 95% CI: -1.17, approximately -1.40, P = 0.01).

CONCLUSIONS

Brief interventions based on motivational interviewing with a telephone booster using personalized feedback were most effective at achieving reductions in alcohol intake across the 3 trauma centers.

Disseminating alcohol screening and brief intervention at trauma centers: a policy-relevant cluster randomized effectiveness trial

BACKGROUND AND AIMS

In 2005 the American College of Surgeons passed a mandate requiring that level I trauma centers have mechanisms to identify and intervene with problem drinkers. The aim of this investigation was to determine if a multi-level trauma center intervention targeting both providers and patients would lead to higher-quality alcohol screening and brief intervention (SBI) when compared with trauma center mandate compliance without implementation enhancements.

DESIGN

Cluster randomized trial in which intervention site (site n = 10, patient n = 409) providers received 1-day workshop training on evidence-based motivational interviewing (MI) alcohol interventions and four 30-minute feedback and coaching sessions; control sites (site n = 10, patient n = 469) implemented the mandate without study team training enhancements.

SETTING

Trauma centers in the United States of America.

PARTICIPANTS

A total of 878 blood alcohol-positive in-patients with and without traumatic brain injury (TBI).

MEASUREMENTS

MI skills of providers were assessed with fidelity coded standardized patient interviews. All patients were interviewed at baseline and 6- and 12-months post-injury with the Alcohol Use Disorders Identification Test (AUDIT).

FINDINGS

Intervention site providers consistently demonstrated enhanced MI skills compared with control providers. Intervention patients demonstrated an 8% reduction in AUDIT hazardous drinking relative to controls over the course of the year after injury (relative risk = 0.88, 95%, confidence interval = 0.79, 0.98). Intervention patients were more likely to demonstrate improvements in alcohol use problems in the absence of traumatic brain injury (TBI) (P = 0.002).

CONCLUSION

Trauma center providers can be trained to deliver higher-quality alcohol screening and brief intervention (SBI) than untrained providers, which is associated with modest reductions in alcohol use problems, particularly among patients without TBI.

Adapting a blended motivational interviewing and problem-solving intervention to address risky substance use amongst South Africans

The purpose of this study was to examine the acceptability and initial substance use outcomes of a blended motivational interviewing (MI) and problem-solving therapy (PST) intervention, delivered by peer counsellors. Twenty people who scored at risk for substance use according to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) received a five session blended MI-PST intervention and were assessed at baseline and at three months. An open-ended semi-structured interview, designed to identify possible factors that may hinder or promote the acceptability of the intervention was also conducted. Fifteen participants completed the intervention and the three-month follow-up. According to ASSIST scores, participants significantly reduced their substance use (p > 0.001) at the three-month follow-up. Randomized controlled trials are needed to evaluate the effect of this intervention more rigorously.

Pharmacists Who Screen and Discuss Opioid Misuse With Patients

Background:

Prescription opioid (PO) abuse has reached epidemic proportions in the United States, and pharmacies are locations from which these medications are often diverted. This study identifies factors associated with pharmacists who currently screen and discuss PO misuse with patients.

Methods:

A secondary data analysis of a cross-sectional Web-based survey that was sent to pharmacists was conducted. The survey contained items that assessed whether pharmacists currently screened and discussed PO misuse with patients along with pharmacists’ attitudes and beliefs toward providing brief interventions. Multivariable models were developed which identified factors associated with pharmacists’ currently screening and discussing misuse.

Results:

Chain setting pharmacists (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 1.16-32.72) and pharmacists interested in being directly involved in PO screening and brief intervention research projects (OR = 2.06, 95% CI = 1.35-3.15) were most likely to report current screening. Pharmacists who reported currently screening for misuse (OR = 4.27, 95% CI = 2.83-6.45) and who reported wanting to help patients who misuse POs (OR = 3.03, 95% CI = 1.50-6.15) were most likely to currently discuss abuse.

Conclusions:

Investigators implementing pharmacy-based screening and brief intervention studies for POs should take into account practice location and pharmacists’ interest in addressing PO issues.

Alcohol and Other Drug Use during Pregnancy among Women Attending Midwife Obstetric Units in the Cape Metropole, South Africa

Little is known about the nature and extent of alcohol and other drug (AOD) use among pregnant women in Cape Town, South Africa, despite the very high levels of AOD use in this part of the country. A cross-sectional survey was conducted among pregnant women attending 11 Midwife Obstetric Units (MOUs) in greater Cape Town. A two-stage cluster survey design was used. In total, 5231 pregnant women were screened to assess self-reported prevalence estimates. Of these, 684 (13.1%) were intentionally subsampled and completed an interviewer-administered questionnaire and provided a urine sample for biological screening. Urinalyses showed that 8.8% (95% CI: 6.7–10.9) of the subsample tested positive for at least one illicit drug. This is higher than the self-reported prevalence (3.6%). In addition, 19.6% (95% CI: 16.3–22.8) of the sub-sample tested positive for alcohol which is lower than the self-reported prevalence (36.9%). There are high levels of substance use among pregnant women attending public sector antenatal clinics. There is a need for routine screening for AOD use and appropriate responses depending on the women's level of risk.

Perceptions of adult trauma patients on the acceptability of text messaging as an aid to reduce harmful drinking behaviours

Background

Brief interventions (BIs) have been shown to be effective in modifying hazardous drinking behaviours in a range of settings. However, they are underutilised in hospitals due to resource constraints. We explored the perspectives of admitted trauma patients about the appeal, acceptability and content of a Brief Intervention (BI) delivered via text messages.

Methods

Thirty mobile phone users (≥16 years old) admitted to Auckland City Hospital as a result of injury were recruited (December 2010 – January 2011). Participants were interviewed face-to-face during their hospital stay using a semi-structured interview guide that explored topics including perceptions of the proposed intervention to reduce hazardous drinking and related harm, and perceived acceptability of an m-health program. Where issues relating to content of messages were raised by participants these were also captured. In addition, a brief survey captured information on demographic information, mobile phone usage and type of phone, along with the frequency of alcohol use.

Results

22 of the 30 participants were male, and almost half were aged 20 to 39 years. The majority of participants identified as New Zealand Europeans, six as Māori (New Zealand's indigenous population) and of the remainder two each identified as Pacific and of Asian ethnicity. Most (28/30) participants used a mobile phone daily. 18 participants were deemed to be drinking in a non-hazardous manner, seven were hazardous drinkers, and three were non-drinkers. Most participants (21/30) indicated that text messages could be effective in reducing hazardous drinking and related harms, with more than half (17/30) signalling they would sign-up. Factors identified that would increase receptiveness included: awareness that the intervention was evidence-based; participants readiness-to-change; informative messages that include the consequences of drinking and practical advice; non-judgemental messages; and ease-of-use. Areas of potential concern included: confidentiality and frequency of messages. The cultural relevance of the messages for Māori was highlighted as important.

Conclusions

This study indicates that trauma patients recognize potential benefits of mobile-health interventions designed to reduce hazardous drinking. The feedback provided will inform the development of an intervention to be evaluated in a randomised controlled trial.

Interpreting null findings from trials of alcohol brief interventions

The effectiveness of alcohol brief intervention (ABI) has been established by a succession of meta-analyses but, because the effects of ABI are small, null findings from randomized controlled trials are often reported and can sometimes lead to skepticism regarding the benefits of ABI in routine practice. This article first explains why null findings are likely to occur under null hypothesis significance testing (NHST) due to the phenomenon known as "the dance of the p-values." A number of misconceptions about null findings are then described, using as an example the way in which the results of the primary care arm of a recent cluster-randomized trial of ABI in England (the SIPS project) have been misunderstood. These misinterpretations include the fallacy of "proving the null hypothesis" that lack of a significant difference between the means of sample groups can be taken as evidence of no difference between their population means, and the possible effects of this and related misunderstandings of the SIPS findings are examined. The mistaken inference that reductions in alcohol consumption seen in control groups from baseline to follow-up are evidence of real effects of control group procedures is then discussed and other possible reasons for such reductions, including regression to the mean, research participation effects, historical trends, and assessment reactivity, are described. From the standpoint of scientific progress, the chief problem about null findings under the conventional NHST approach is that it is not possible to distinguish "evidence of absence" from "absence of evidence." By contrast, under a Bayesian approach, such a distinction is possible and it is explained how this approach could classify ABIs in particular settings or among particular populations as either truly ineffective or as of unknown effectiveness, thus accelerating progress in the field of ABI research.

Mechanisms of action of brief alcohol interventions remain largely unknown - a narrative review

A growing body of evidence has shown the efficacy of brief intervention (BI) for hazardous and harmful alcohol use in primary health care settings. Evidence for efficacy in other settings and effectiveness when implemented at larger scale are disappointing. Indeed, BI comprises varying content; exploring BI content and mechanisms of action may be a promising way to enhance efficacy and effectiveness. Medline and PsychInfo, as well as references of retrieved publications were searched for original research or review on active ingredients (components or mechanisms) of face-to-face BIs [and its subtypes, including brief advice and brief motivational interviewing (BMI)] for alcohol. Overall, BI active ingredients have been scarcely investigated, almost only within BMI, and mostly among patients in the emergency room, young adults, and US college students. This body of research has shown that personalized feedback may be an effective component; specific MI techniques showed mixed findings; decisional balance findings tended to suggest a potential detrimental effect; while change plan exercises, advice to reduce or stop drinking, presenting alternative change options, and moderation strategies are promising but need further study. Client change talk is a potential mediator of BMI effects; change in norm perceptions and enhanced discrepancy between current behavior and broader life goals and values have received preliminary support; readiness to change was only partially supported as a mediator; while enhanced awareness of drinking, perceived risks/benefits of alcohol use, alcohol treatment seeking, and self-efficacy were seldom studied and have as yet found no significant support as such. Research is obviously limited and has provided no clear and consistent evidence on the mechanisms of alcohol BI. How BI achieves the effects seen in randomized trials remains mostly unknown and should be investigated to inform the development of more effective interventions.

Brief interventions for hazardous and harmful alcohol consumption in accident and emergency departments

The prevalence of alcohol abuse among patients treated in accident and emergency departments (A&E) is considered as substantial. This paper is a narrative review of studies investigating the effectiveness of brief interventions (BI) for hazardous and harmful alcohol consumption in A&E. A&E departments in hospitals (and other health care infrastructures) are commonly the place where serious consequences of alcohol drinking are seen and need to be tackled, supporting the suggested theoretical usefulness of delivering BI in this environment. Available research shows that BI may be considered a valuable technique for dealing with alcohol-related problems. However, it is suggested that the usefulness of BI may depend significantly on the target population to be dealt with. BI have proved to be beneficial for male individuals and those patients who do not abuse other psychoactive substances. In contrast, evidence indicates that BI in A&E settings are not effective at all when dealing with men admitted as a consequence of a violence-related event. In addition, some studies were unable to confirm the effectiveness of BI in female population, in emergency setting. Studies investigating the association between drinking patterns and the effectiveness of BI also present inconsistent results. Most studies assessing the effectiveness of BI in A&E settings only adopted a short perspective (looking at the impact up to a maximum of 12 months after the BI was delivered). When assessing the effects of BI, both the amount of alcohol consumed and expected reductions in alcohol consequences, such as injuries, can be taken into account. Evidence on the implementation of brief intervention in emergency departments remains inconclusive as to whether there are clear benefits. A variety of outcome measures and assessing procedures were used in the different studies, which have investigated this topic.

Characteristics and treatment interests among individuals with substance use disorders and a history of past six-month violence: findings from an emergency department study

The study examined clinical characteristics and treatment interests of individuals identified to have substance use disorders (SUDs) in an urban emergency department (ED) who reported past six-month history of violence or victimization. Specifically, participants were 1441 ED patients enrolled in a randomized controlled trial of interventions designed to link those with SUDs to treatment. To examine factors related to violence type, four groups based on participants' reports of violence toward others were created: no violence (46.8%), partner violence only (17.3%), non-partner violence only (20.2%), and both partner and non-partner violence (15.7%). Four groups based on participants' reports of victimization were also created: no violence (42.1%), victimization from partner only (18.7%), victimization from non-partner only (20.2%), and both partner and non-partner victimization (17.7%). Separate multinomial logistic regression analyses were conducted to examine which variables distinguished the violence and victimization groups from those reporting no violence or victimization. For violence toward others, demographic variables, alcohol and cocaine disorders, and rating treatment for psychological problems were higher for violence groups, with some differences depending on the type of violence. For victimization, demographic variables, having an alcohol disorder, and rating treatment for family/social problems were higher for violence groups, also with some differences depending on the type of violence. Findings from the present study could be useful for designing effective brief interventions and services for ED settings.

Risk factors for subsequent impaired driving by injured passengers

OBJECTIVES

The purpose of this study was to evaluate the rate of, and risk factors for, subsequent impaired driving activity (IDA) in a cohort of injured passengers who were treated for injuries in a Canadian trauma center.

METHODS

We studied adult passengers who were occupants in vehicles involved in motor vehicle crashes (MVCs) and either included in the British Columbia (BC) trauma registry (January 1, 1992-December 31, 2004) or treated in the emergency department (ED) of Vancouver General Hospital (VGH; January 1, 1999-December 31, 2003). Passengers were linked to their driver's license and hence to their driving record using personal health number and demographic information. Injured passengers were stratified into 3 groups based on their blood alcohol concentration (BAC) at time of ED presentation: group 1: BAC = 0, group 2: 0 < BAC ≤ 17.3 mM (0.08%), group 3: BAC > 17.3 mM (0.08%). Two outcome variables were studied: involvement in a subsequent IDA and time to their first subsequent IDA. IDA was defined as a criminal code conviction for impaired driving, a 24-h or 90-day license suspension for impaired driving, and/or involvement in an MVC where police cited alcohol as a factor. Time to first IDA following the index event among passenger BAC groups was compared with Kaplan-Meier survival analysis. Cox proportional hazards models were employed to examine the effect of various potential risk factors on time to engage in first IDA.

RESULTS

Injured passengers with any BAC at the time of ED visit were more likely to engage in IDA and had their first IDA sooner after the index event than those with zero BAC. Among this cohort of injured passengers, 12.1 percent with BAC = 0, 29.9 percent with 0 < BAC ≤ 17.3 mM (0.08%), and 37.8 percent with a BAC > 17.3 mM (0.08%) engaged in IDA. Compared to passengers with BAC = 0, group 3 passengers and group 2 passengers were 2.06 times and 1.79 times more likely to engage in future IDA. Twenty-five percent of injured passengers engaged their first IDA by 57 and 38 months in groups 2 and 3, respectively. Previous IDA and being male were also significant risk factors for future IDA. Those with a history of IDA before the index event were 2.37 times more likely to engage in subsequent IDA.

CONCLUSIONS

Injured alcohol-impaired passengers are at high risk for IDA and should be included in impaired driving prevention programs.

A systematic review of emergency department interventions for college drinkers

BACKGROUND

Alcohol use in college-age individuals is associated with increased injury risk. Many college drinkers end up in the emergency department (ED) as a result of their drinking, providing a unique opportunity to intervene.

OBJECTIVE

This systematic review evaluates the existing evidence for the use of brief ED interventions for alcohol use in the college-age population.

METHODS

A systematic search of on-line databases was conducted. Articles were limited to those in English published since 1990. Studies were included if they specifically studied 18- to 20-year-old alcohol users, if they were performed in an ED or acute care setting, and if an intervention regarding alcohol use was attempted.

RESULTS

There were 400 studies identified; 60 abstracts were reviewed, 18 full-text articles were evaluated, and 7 met the inclusion criteria for review. Eligible studies focused on alcohol use only, except for one study that addressed alcohol and other drug use. All examined changes in alcohol intake patterns as a primary outcome, and most also looked for reductions in alcohol-related harm. Each found reductions in alcohol intake patterns or reductions in alcohol-related harm in the intervention group, although some between-group differences were not statistically significant reductions.

CONCLUSION

Seven studies were identified that measured the outcomes of ED interventions for alcohol use in the college-age population. The studied interventions showed promise but had variable success. More research is needed to establish short- and long-term efficacy, specifically in high-risk underage college students.

Computer-enhanced interventions for drug use and HIV risk in the emergency room: preliminary results on psychological precursors of behavior change

This article describes process data from a randomized controlled trial among 781 adults recruited in the emergency department who reported recent drug use and were randomized to: intervener-delivered brief intervention (IBI) assisted by computer, computerized BI (CBI), or enhanced usual care (EUC). Analyses examined differences between baseline and post-intervention on psychological constructs theoretically related to changes in drug use and HIV risk: importance, readiness, intention, help-seeking, and confidence. Compared to EUC, participants receiving the IBI significantly increased in confidence and intentions; CBI patients increased importance, readiness, confidence, and help-seeking. Both groups increased relative to the EUC in likelihood of condom use with regular partners. Examining BI components suggested that benefits of change and tools for change were associated with changes in psychological constructs. Delivering BIs targeting drug use and HIV risk using computers appears promising for implementation in healthcare settings. This trial is ongoing and future work will report behavioral outcomes.

Screening and brief interventions for substance use in emergency departments in the Western Cape province of South Africa: views of health care professionals

As part of the formative phase of screening and brief interventions (SBIs) for substance use amongst patients presenting for emergency services in South Africa, the present study explored health care providers' attitudes and perceptions towards SBI. Twenty-four health care providers working in two 24-hour emergency departments (EDs) were interviewed using an open-ended semi-structured interview schedule designed to identify factors that may hinder or promote the implementation of SBI for substance use in these settings. All respondents felt that screening patients for substance use in EDs is possible; however, they emphasised the need for an additional staff member dedicated to these activities. Secondly, they felt this dedicated individual should meet certain educational criteria and be from a specific socio-demographic background in order to increase the likelihood of intervention uptake. Thirdly, a number of patient- and clinic-level barriers were revealed that could potentially hinder the successful implementation of SBIs in EDs.

Interventions for reducing alcohol consumption among general hospital inpatient heavy alcohol users: a systematic review

BACKGROUND

There is growing interest in pro-active detection and provision of interventions for heavy alcohol use in the general hospital inpatient population. We aimed to determine, from the available evidence, the effectiveness of interventions in reducing alcohol consumption among general hospital inpatient heavy alcohol users.

METHODS

The following databases were searched for completed and on-going randomised and non-randomised controlled studies published up to November 2012: MEDLINE; C2-SPECTR; CINAHL; The Cochrane Library; Conference Proceedings Citation Index: Science; EMBASE; HMIC; PsycInfo; Public Health Interventions Cost Effectiveness Database (PHICED); and ClinicalTrials.gov. Studies were screened independently by two reviewers. Data extraction was performed by one reviewer and independently checked by a second.

RESULTS

Twenty-two studies which met the inclusion criteria enrolled 5307 participants in total. All interventions were non-pharmacological and alcohol focused. Results from single session brief interventions and self-help literature showed no clear benefit on alcohol consumption outcomes, with indications of benefit from some studies but not others. However, results suggest brief interventions of more than one session could be beneficial on reducing alcohol consumption, especially for non-dependent patients. No active intervention was found superior over another on alcohol consumption and other outcomes.

CONCLUSIONS

Brief interventions of more than one session could be beneficial on reducing alcohol consumption among hospital inpatients, especially for non-dependent patients. However, additional evidence is still needed before more definitive conclusions can be reached.

Motivational counseling reduces future police charges in court referred youth

By the age of 18, between 16 and 27% of adolescents in the U.S. have been arrested for an offense and by the age of 23 this increases to a staggering 25-41%. Most youth that get into legal trouble have a substance abuse problem and many youth report high risk driving behaviors. Adjudication of adolescents for an offense may provide an opportunity to provide a secondary prevention program for such high risk behaviors. In this regard the primary aim of the present study was to test two hypotheses: (1) that interventions involving group motivational interviewing would decrease future legal charges beyond those achieved by the combination of sanctions and remedial actions otherwise mandated by the court; and (2) that the addition of a trauma room exposure to the group MI intervention would increase the effectiveness of MI in decreasing these future legal charges. Court mandated youth who have had a high risk driving police charge and/or alcohol related police charge and who are drivers (n=992) were randomly assigned to one of the three 20h interventions; enhanced prototypic community service (CS), Motivational Intervention with typical community service (MI), and Motivational Intervention with exposure to a hospital trauma center (MI-H). As hypothesized, the probability of being charged with an offense within the 6 months post-treatment was significantly less for participants in the combined MI groups than those in the CS group. The combined MI groups also had significantly fewer overall number of police charge events than the CS group at 6 months. Mediation analyses revealed that the relationship between MI vs. CS interventions and subsequent police charges was partially accounted for by the youth's experience of the MI component of the intervention. Despite fewer police charges at 6 months the combined MI group reported (1) significantly more hazardous drinking and (2) a greater amount of speeding and distracted driving than the control group over this same 6-month period. Hypothesis 2, that MI-H would be more effective than MI in reducing police charges, was not supported. This was so despite evidence supporting the hypotheses that (1) trauma room exposure would increase participants' emotional arousal during the intervention and (2) increased arousal would be predictive of fewer police charges. Despite support for the theorized causal pathway, the combination of trauma room exposure and MI did not result in better outcomes than MI combined with traditional community service. Given this discrepancy between empirical supports for the theory in the face of the absence of incremental effectiveness of the MI-H treatment condition, a better understanding of the participant's hospital experience will be necessary if we are to successfully utilize the trauma room exposure to increase the effectiveness of MI interventions for this target group to achieve better outcomes.