Alcohol Screening and the Brief Negotiated Intervention (BNI).What is it & Does it Work?

Several Truths

Treatment does work The ED/Primary care visit is an opportunity

for intervention Timely referral is effective Practitioners are reluctant to screen and

intervene There are multiple barriers to the SBI

Alcohol Screening in the ED

Why should we care?

Why Do We Care?

Prevalence

Morbidity & Mortality

Diminished Quality of Life

Harm to Self & Others

Alcohol Abuse Effects

$100 billion annual national cost $27 billion is from lost productivity 111 million US regular alcohol users 34% of persons 19-28 years engage in binge

drinking or drank heavily in past 30 days

Dept Health & Human Services, 8th congressional report, 1993x

National Hospital Ambulatory Medical Care Survey 2001 Emergency Department Summary

107.5 million visits 38.4/100 persons

39.4 million injury visits 14.1/100 persons

4.1 hour mean alcohol visit duration

2.5 million (2.3%) documented alcohol related

visits

11.4% referrals for alcohol treatment

Scope of the Problem

31% of adults presenting to and urban ED

reported > to 2 CAGE positive (Bernstein 1996)

24% of adults presenting by ambulance to an

urban ED reported > 2 CAGE positive (Whiteman 2000)

ED patients are 1.5-3.0 times more likely to report

heavy drinking or consequences than those in

Primary Care (Cherpitel 1999)

Morbidity and Mortality

>107,000 alcohol related deaths each year

1/3 of adult admissions are alcohol related

Attributable risk factor for multiple illnesses

Major risk factor for all categories of injury

– Problem drinkers have 2x injury events/yr and 4x as many hospitalizations for injury

– A single alcohol-related visit predicts continued problem drinking

Alcohol-Related Fatalities

0

2,500

5,000

7,500

10,000

12,500

15,000

17,500

20,000

22,500

25,000

27,500

82 84 86 88 90 92 94 96 98 00 02 04

Young Adults

17% of 8th graders, 33% of 10th graders & 47% of 12th graders report alcohol use in the past month

11% of 8th graders, 21% of 10th graders & 28% of 12th graders report binge drinking (5 drinks in a row) in the past two weeks

Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey, 2005. www.monitoringthefuture.org

Young Adults

Highest prevalence of alcohol consumption

Major concern for college campuses

Drivers between the ages of 16-25 account for 30% of alcohol-related fatalities

Americans 18 and older

10 million (5%) dependent drinkers 40 million (20%) high risk drinkers 70 million (35%) moderate drinkers 80 million (40%) abstain

National Longitudinal Alcohol Epidemiologic Survey, 1992

Elderly

10% of ED patients with alcohol problems

are > 60 years of age

Increased sensitivity to alcohol effects

Associated with depression and suicide

attempts

At risk for medication interactions

Ambulatory medical care survey

Nation’s Public Health Agenda:Healthy People 2010

Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these problems in the emergency department

Why Early intervention?

Screening and referral increases treatment contact

$ saved Improved prognosis Medical opportunity is ‘Teachable

Moment’

UNIVERSAL SCREENING UNIVERSAL SCREENING WIDENS THE NETWIDENS THE NET

ABSTAINERS & MILD DRINKERS

(70%)

MODERATE(20%)

at risk drinkers

SEVERE (10%)

Primary Prevention

Brief Intervention

Specialized Treatment

Importance of Detection

Davidson, et al noted that a single alcohol related ED visit is an important predictor of continued problem drinking, alcohol impaired driving, and, possibly, premature death

Davidson et al. Ann Emerg Med. 1997

Detection and Referral

Does it matter?????

Fleming

“Brief physician advice for problem alcohol drinkers: a randomized control trial in community-based primary care practices”

BI in 17 practices with 64 physicians

Intervention included: educational workbook,

(2) 15 minute visits one month apart, and

(2) nurse follow-up calls, 2 weeks after the visit

Fleming et al. JAMA 1997;277:1039-1047

Fleming

Results at 12 months (n=723)

Consumption:

(I) 19.1 drinks/wk to 11.5 vs (C) 18.9 to 15.2

Episodes of binge drinking during prior 30 days:

(I) 5.7 to 3.1 vs (C) 5.3 to 4.2

COST-BENEFIT ANALYSIS OF BRIEF MOTIVATION

RCT (n=774) primary care practice, managed care setting problem drinkers economic cost of intervention = $80,210 ($205 each) economic benefit of intervention = $423,519

– $193,448 in ED and hospital use

– $228,071 avoided costs in motor vehicle crashes and crime

– 5.6 to 1 benefit to cost ratio

– $6 savings for every $ invested

Fleming MF, et al. Medical Care 2000; 38:7-18.

World Health Organization(Am J Pub Health 1996)

“A cross-national trial of brief interventions with heavy drinkers”– Multinational study in 10 countries (n=1,260)– Interventions included simple advice, brief &

extended counseling compared to control group– Results: Consumption decreased:

• 21% with 5 minutes advice, 27% with 15 minutes compared to 7% controls

• Significant effect for all interventions

Adolescents BNIMonti, et al“Brief intervention for harm reduction with

alcohol-positive older adolescents in an ED” 94 patients (18-19 years) were randomized (I) group had a significant reduction in alcohol use

(p<.001) at 6 month f/u and were less likely to report:– having driven after drinking ( p<0.05),

– having had alcohol involved in an injury (p<0.01)

– to have had alcohol-related problems (p<0.05)

Adolescents BNIMonti, et al94 Randomized 87 completed 3 month, 84 (89%) completed

6 month

Monti, et al. J of Consulting and Psychology. 1999;67:6.

Still engaging in this behavior

Adolescents BNIMonti, et al

BNI SC

Drinking & Driving

62% 85%

Moving Violations

3% 23%

Alcohol related injuries

21% 50%

Longbaugh et al

386 patients entered 3 groups: Control, Intervention and

Intervention with a booster session The Brief intervention with booster showed

the best results.

Longbaugh. J of Studies on Alcohol. Nov 2001.

Gentilello et al. Annals Surgery1999;230:473-483

“Alcohol Interventions in a Trauma Center as a Means of Reducing Risk of Injury Recurrence”

– Admitted injured patients who tested and/or screened positive for alcohol problems were randomized (n=732)

– Results at 12 months (54% follow-up rate):

• (I) alcohol consumption 21.8 drinks/week vs. (C) 6.7 (p=0.03)

Gentilello

• Reduction most apparent in mild-mod drinkers: 21.6 drinks/week vs 2.3 drinks/week in controls (p<0.01)

• 47% reduction in new injuries requiring ED visit or readmission to the trauma service (p=0.07)

• 48% reduction in new injuries requiring hospitalization at 3-year follow-up

Ok, What is the Brief Negotiated Interview & How do I perform this technique?

Components of the BNI

1. Raise the Subject

2. Provide Feedback

3. Enhance Motivation

4. Negotiate and Advise

Step 1: Raise The Subject

Establish Rapport Raise the subject of alcohol use

“Hello, I am….... Would you mind taking a few minutes to talk with me about your alcohol use?”

Establish Rapport

To understand the patient’s concerns and circumstances

To explain the providers concern/role

To avoid a judgmental stance

Raise the subject Get the patient’s agreement to talk

about the alcohol or drug use

Talk about the pros and cons of their use/abuse

Re-state what they have said regarding the pros and cons

What if the patient does not want to talk about their use/abuse ?

“ Okay, I see you aren’t ready to talk about this today. Remember that we are here 24 / 7 if you change your mind”

ASK Current Drinkers

• On average, how many days per week do you

drink alcohol?

• On a typical day when you drink, how many

drinks do you have?

• What’s the maximum number of drinks you

had on a given occasion in the last month?

Screen Positive

Drinks per

week

Drinks per occasion

Men > 14 > 4

Women > 7 > 3

All Age >65 > 7 > 3

Drinking Patterns% of

US adults aged 18+

Abusewithout

dependence

Dependencewith or without

abuse

Exceeds daily limit< once a week

16% 1 in 8(12%)

1 in 20(5%)

Exceeds daily limitonce a week or more

3% 1 in 5(19%)

1 in 8(12%)

Exceeds bothweekly & daily limits

9% 1 in 5(19)

1 in 4(28)

Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003

ASK Current Drinkers

CAGE

C Cut DownA AnnoyedG GuiltyE Eye Opener

Step 2: Provide Feedback

Review patient’s drinking patterns Make connection to ED visit if possible Compare to National Norms and offer

NIAAA guidelines

Step 2: Provide Feedback

“From what I understand you are drinking…”

“What connection (if any) do you see between your drinking and this ED visit?”

“These are what we consider to be the upper limits of low-risk drinking for your age and sex. By low-risk we mean that you would be less likely to experience illness or injury.”

Express Empathy and Rapport

Attitude : Acceptance by provider

Technique: Skillful reflective listening

Basis of change: Patient ambivalence

Assess Readiness To Change

“On a scale of 1-10 (1 being not ready and 10 being very ready) how ready are you to change any aspect your drinking patterns?”

1 2 3 4 5 6 7 8 9 10

Step 3: Enhance Motivation

“On a scale from 1-10, how ready are you to change any aspect of your drinking?

If patient indicates:

> 2 : “Why did you choose that number and not a lower one? What are some

reasons that you are thinking about changing.”

< 1: “Have you ever done anything that you wish you hadn’t while drinking: What would

make this a problem for you.” Discuss pros and cons

Not Ready for Change

Don’t – Use shame or blame– Preach– Label– Stereotype– Confront

Avoid Argumentation

Counter productive Defending breeds defensiveness Perceptions can be shifted Labeling is unnecessary Resistance is a signal to change strategies

– Rolling with resistance

Not Ready for change

Do– Offer information, support and further contact– Present feedback and concerns, if permitted– Negotiate: “What would it take you to consider

a change ?”

Unsure Patients

Don’t– Jump ahead

– Give advice

– Expect argument about change

Do– Explore pros & cons

– “help me to understand what alcohol does for you”

– “Are there things you don’t like about your alcohol use?”

Step 4: Negotiate and Advise

Elicit response “How does all this sound to you?”

Negotiate a goal“What would you like to do?”

Give advice“It is never safe to drink and drive, etc…”

Summarize“This is what I heard you say.. Thank you… (Provide PCP f/u or treatment referral)

Develop DiscrepancyExplore Pros and Cons Patient awareness of situation

Discrepancy between present behavior and important goals as change motivator

Let the patient name the problem and the pros and cons

Dangerous Assumptions

This person ought to change This person is ready to change This person’s health is the prime motivating

factor for them If they decide not to change the BNI has

failed

Dangerous Assumptions

Patients are either motivated or not Now is the right time to change A tough approach is best I am the expert and they should follow my

advice

The Ready Patient

Help the patient to:– Name a solution for themselves– Choose a course of action– Decide how to achieve it– Encourage patient choice

Referral

Consult the– Social worker– Psychiatric services

Discharge sheet of possible centers and / or programs and information

Summary

Alcohol problems are common, identifiable

and treatable disorders

Knowledge and skills for screening and

intervention can be learned

Remember:

Just start the conversation,

you may save a life!