Alcohol, tobacco, and other drugs: future directions for screening and intervention in the emergency department

Promoting tobacco cessation utilizing pre-health professional students as research associates in the emergency department

OBJECTIVE

The objective of this study was to investigate the extent to which volunteer research associates (RAs) can be utilized to screen emergency department patients and their visitors for tobacco use and effectively refer tobacco users requesting help to state Tobacco Quitlines.

METHODS

A sample of 19,149 individuals in 10 emergency departments around the country was enrolled into a prospective, interventional study on tobacco cessation by pre-health professional RAs. Participants who screened positive for tobacco use were provided a brief description of Tobacco Quitline programs and then offered a faxed referral to their respective state Quitline.

RESULTS

A total of 10,303 (54%) participants reported tobacco use for more than one month during their lives, with 3861 (20%) currently using every day and an additional 1340 using on some days (7%). Most importantly, 2151 participants requested a faxed Tobacco Quitline referral (36% of individuals who used tobacco in the past month).

DISCUSSION

Pre-health professional RAs were shown to be an effective and cost-efficient resource for providing a strongly recommended service in the emergency department. Patient care (and the care of their visitors) was supplemented, emergency department personnel were not provided with additional burden, and RAs were provided with valuable experience for their futures in the health professions.

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.

Past blood alcohol concentration and injury in trauma center: propensity scoring

BACKGROUND

Evidence linking alcohol use to injury outcomes remains inconclusive, with prehospital and police department-based studies showing negative effects and hospital-based studies showing no effect or better outcomes.

OBJECTIVE

The purpose of this study was to examine the relationship of blood alcohol concentration (BAC) with injury characteristics and outcomes among trauma patients admitted to a major teaching hospital. In an effort to mitigate selection and confounding bias, propensity scoring methodology was applied, by which trauma patients were randomly assigned to high- and low-BAC groups.

METHODS

Electronic medical records were retrospectively reviewed for a period of 8 months. Of 1057 patients whose BAC was determined, 667 had BAC ≤ 0.08 g/dL and 390 had BAC > 0.08 g/dL. Injury characteristics were defined as injury type, injury location, and trauma level. Injury outcomes were defined as hospitalization, length of hospital stay, and in-hospital death. Adjusted odds ratios (aOR) and their 95% confidence intervals (CI) were calculated using multivariate logistic regression models and propensity scoring was applied.

RESULTS

A positive relationship was observed between BAC and unintentional injury (aOR = 1.08; 95% CI 1.01-1.17). Although injuries of the extremities were less likely to occur in patients with high BAC (aOR = 0.88; 95% CI 0.80-0.98), head injury was positively associated with high BAC (aOR = 1.27; 95% CI 1.14-1.42). Also, Level I trauma patients had nearly 60% greater odds of having a high BAC than Level II trauma patients.

CONCLUSIONS

A high alcohol level in the blood appears to be predictive of more unintentional injury, head injury, and Level I trauma activation and less injuries in extremities.

Motivation to quit smoking in parental smokers in the pediatric emergency department

OBJECTIVE

To examine if motivation to quit is associated with parental smoker's perceived presence of a personal or child health illness or risk due to tobacco use.

DESIGN/METHODS

This was a cross-sectional study of a convenience sample of 218 parental smokers who presented to the pediatric emergency department with their child. We assessed factors related to motivation to quit, including personal and child smoking-related illness, perceived personal and child health risk, smoking behaviors, and demographic characteristics. Motivation to quit was measured using the Contemplation Ladder score.

RESULTS

The mean score on the Contemplation Ladder was 6.2 (SD, 2.5), representing the response: thinking about cutting down or quitting . Eighty-four participants (39%) had high motivation to quit (Contemplation Ladder score 8). Bivariate analysis showed significant associations between high motivation to quit and perceived child health risk with continued smoking and perceived personal and child health benefit following smoking cessation. Parents with high motivation to quit were more likely to have high perceived self-efficacy and confidence in their ability to quit, prior quit attempts, and lower nicotine dependence. With the exception of race/ethnicity, demographic variables were not associated with motivation to quit.

CONCLUSIONS

A significant proportion of parental smokers who present to the pediatric emergency department endorse strong motivation to quit. Parents who endorse health risk or quitting-related health benefits in their child are more likely to have high motivation to quit smoking. Future studies are needed to determine if high motivation translates into smoking cessation.

The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

Background

Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial.

Methods and Findings

Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings.

Conclusions

SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions.

Trial Registration

Current Controlled Trials ISRCTN 93681536

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.

Assessment of alcohol use patterns among spanish-speaking patients

OBJECTIVE

The objective of this study was to assess drinking patterns of Spanish-speaking patients using a bilingual computerized alcohol screening and brief intervention (CASI) tablet computer equipped with the Alcohol Use Disorders Identification Test (AUDIT).

METHODS

This retrospective study was conducted in a tertiary university hospital emergency department (ED) between 2006 and 2010. Data from 1816 Spanish-speaking ED patients were analyzed using descriptive statistics, the chi-square test for independence, and the Kruskal-Wallis rank sum test for comparisons using quantitative variables.

RESULTS

Overall, 15% of Spanish-speaking patients were at-risk drinkers, and 5% had an AUDIT score consistent with alcohol dependency (≥20). A higher percentage of Spanish-speaking males than females were at-risk drinkers or likely dependent. Spanish-speaking males exhibited higher frequency of drinking days per week and higher number of drinks per day compared with females. Among older patients, nondrinking behavior increased and at-risk drinkers decreased. The majority of males and females were ready to change their behavior after the CASI intervention; 61% and 69%, respectively, scored 8-10.

CONCLUSIONS

This study indicated that CASI was an effective tool for detecting at-risk and likely dependent drinking behavior in Spanish-speaking ED patients. The majority of patients were ready to change their drinking behavior. More alcohol screening and brief intervention tools should be tested and become readily accessible for Spanish-speaking patients.

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.

Incorporating screening, brief intervention, and referral to treatment into emergency nursing workflow using an existing computerized physician order entry/clinical decision support system

INTRODUCTION

The objective of this study was to evaluate whether screening, brief intervention, and referral to treatment (SBIRT) could be incorporated into the emergency nursing workflow using a computerized physician order entry/clinical decision support system. We report demographic and operational factors associated with failure to initiate the protocol and revenue collection from SBIRT.

METHODS

We conducted a retrospective, observational cohort analysis of a protocol adding SBIRT to the emergency nursing workflow of a single, tertiary care urban emergency department for all adult patient visits in 2012. Emergency nurses prescreened for unhealthy alcohol or drug use during triage assessment and, when positive, administered SBIRT during treatment area care, all documented in the computerized physician order entry/clinical decision support system. Using multivariable logistic regression, we report demographic and operational factors associated with failure to initiate the protocol. From October 2012, we submitted charges for brief interventions and analyzed collection results.

RESULTS

The inclusion criteria were met for 47,693 visits. Of these, 39,758 (83.4%) received triage protocol initiation. Variables associated with decreased odds of protocol initiation were younger age (odds ratio [OR] for rising age, 1.044; 95% confidence interval [CI], 1.042-1.045), arrival by ambulance (OR, 0.37; 95% CI, 0.35-0.40), and higher triage acuity (OR, 0.08; 95% CI, 0.07-0.09). Of visits with protocol initiation, 21.4% were documented as positive for at-risk alcohol and/or drug use. However, brief interventions were only administered during 971 visits. During the billing period, $3617.53 was collected on charges of $10,829.15 for 262 completed brief interventions.

DISCUSSION

In this study electronic documentation of adults with at-risk alcohol and/or drug use was feasible by emergency nurses, but SBIRT execution and subsequent revenue collection were challenging.

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.

Evaluation of California's Alcohol and Drug Screening and Brief Intervention Project for Emergency Department Patients

INTRODUCTION

Visits to settings such as emergency departments (EDs) may present a "teachable moment" in that a patient may be more open to feedback and suggestions regarding their risky alcohol and illicit drug-use behaviors. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an 'opportunistic' public health approach that targets low-risk users, in addition to those already dependent on alcohol and/or drugs. SBIRT programs provide patients with comprehensive screening and assessments, and deliver interventions of appropriate intensity to reduce risks related to alcohol and drug use.

METHODS

This study used a single group pre-post test design to assess the effect of the California SBIRT service program (i.e., CASBIRT) on 6 substance-use outcomes (past-month prevalence and number of days of binge drinking, illegal drug use, and marijuana use). Trained bilingual/bicultural Health Educators attempted to screen all adult patients in 12 EDs/trauma centers (regardless of the reason for the patient's visit) using a short instrument, and then delivered a brief motivational intervention matched to the patient's risk level. A total of 2,436 randomly selected patients who screened positive for alcohol and/or drug use consented to be in a 6-month telephone follow-up interview. Because of the high loss to follow-up rate, we used an intention-to-treat approach for the data analysis.

RESULTS

RESULTS of generalized linear mixed models showed modest reductions in all 6 drug-and alcohol-use outcomes. Men (versus women), those at relatively higher risk status (versus lower risk), and those with only one substance of misuse (versus both alcohol and illicit drug misuse) tended to show more positive change.

CONCLUSION

These results suggest that SBIRT services provided in acute care settings are associated with modest changes in self-reported recent alcohol and illicit drug use.

Predictors of Successful Telephone Contact After Emergency Department-based Recruitment into a Multicenter Smoking Cessation Cohort Study

INTRODUCTION

Emergency department (ED) studies often require follow-up with subjects to assess outcomes and adverse events. Our objective was to identify baseline subject characteristics associated with successful contact at 3 time points after the index ED visit within a sample of cigarette smokers.

METHODS

This study is a secondary analysis of a prospective cohort. We recruited current adult smokers at 10 U.S. EDs and collected baseline demographics, smoking profile, substance abuse, health conditions, and contact information. Site investigators attempted contact at 2 weeks, 3 months, and 6 months to assess smoking prevalence and quit attempts. Subjects were paid $20 for successful follow-up at each time point. We analyzed data using logistic and Poisson regressions.

RESULTS

Of 375 recruited subjects, 270 (72%) were contacted at 2 weeks, 245 (65%) at 3 months, and 217 (58%) at 6 months. Overall, 175 (47%) were contacted at 3 of 3, 71 (19%) at 2 of 3, 62 (17%) at 1 of 3, and 66 (18%) at 0 of 3 time points. At 6 months, predictors of successful contact were: older age (adjusted odds ratio [AOR] 1.2 [95%CI, 0.99-1.5] per ↑10 years); female sex (AOR 1.7 [95%CI, 1.04-2.8]); non-Hispanic black (AOR 2.3 [95%CI, 1.2-4.5]) vs Hispanic; private insurance (AOR 2.0 [95%CI, 1.03-3.8]) and Medicare (AOR 5.7 [95%CI, 1.5-22]) vs no insurance; and no recreational drug use (AOR 3.2 [95%CI; 1.6-6.3]). The characteristics independently predictive of the total number of successful contacts were: age (incidence rate ratio [IRR] 1.06 [95%CI, 1.00-1.13] per ↑10 years); female sex (IRR 1.18 [95%CI, 1.01-1.40]); and no recreational drug use (IRR 1.37 [95%CI, 1.07-1.74]). Variables related to smoking cessation (e.g., cigarette packs-years, readiness to quit smoking) and amount of contact information provided were not associated with successful contact.

CONCLUSION

Successful contact 2 weeks after the ED visit was 72% but decreased to 58% by 6 months, despite modest financial incentives. Older, female, and non-drug abusing participants were the most likely to be contacted. Strategies to optimize longitudinal follow-up rates, with limited sacrifice of generalizability, remain an important challenge for ED-based research. This is particularly true for studies on substance abusers and other difficult-to-reach populations.

Assessment of readiness to change and relationship to AUDIT score in a trauma population utilizing computerized alcohol screening and brief intervention

Trauma patient readiness-to-change score and its relationship to the Alcohol Use Disorder Identification Test (AUDIT) score were assessed in addition to the feasibility of computerized alcohol screening and brief intervention (CASI). A bilingual computerized tablet for trauma patients was utilized and the data were analyzed using Stata. Twenty-five percent of 1145 trauma patients drank more than recommended and 4% were dependent. As many Spanish-speaking as English-speaking males did not drink, but a higher percentage of Spanish-speaking males drank more than recommended and were dependent. Half of patients who drank more than recommended rated themselves 8 or higher on a 10-point readiness-to-change scale. CASI also provided personalized feedback. A high percentage of trauma patients (92%) found CASI easy and a comfort in use (87%). Bilingual computerized technology for trauma patients is feasible, acceptable, and an innovative approach to alcohol screening, brief intervention, and referral to treatment in a tertiary care university.

Gender, violence and brief interventions for alcohol in the emergency department

BACKGROUND

The impact of gender and violence on brief interventions (BIs) for alcohol use in the emergency department (ED) has not been studied. Our objective was to examine the effectiveness of alcohol BIs in an ED population stratified by gender and violence.

METHODS

This was a secondary analysis of datasets pooled from three ED-based randomized controlled studies of alcohol BIs. AUDIT-C was the primary outcome measure; secondary outcomes were binge drinking and achievement of NIAAA safe drinking levels. We conducted univariate comparisons and developed generalized linear models (GLM) for the primary outcome and generalized estimating equation (GEE) models for secondary outcomes to examine the intervention effect on the whole study group, gender-stratified subgroups, and gender- and violence-stratified subgroups.

RESULTS

Of 1219 participants enrolled, 30% were female; 31% of women and 42% of men reported violence involvement at baseline. In univariate analysis, no differences in outcomes were found between intervention and control groups for any subgroup. However, in multivariable models, men demonstrated an intervention effect for likelihood of safe drinking limits. Stratifying further by violence, only men without violence involvement demonstrated a positive intervention effect for safe drinking limits. There was no evidence of an intervention effect on women.

CONCLUSIONS

Analyzing the overall effect of ED-based BI may mask its ability to improve alcohol-related outcomes in a subset of the population. Alternatively, interventions may need to be significantly improved in subsets of the ED population, e.g., in women and in men with involvement in violence.

Attitudes and Beliefs towards Patients with Hazardous Alcohol Use: A Systematic Review

Objective. To describe emergency department (ED) staff attitudes and beliefs towards patients presenting with hazardous alcohol use and their clinical management. Methods. A search of MEDLINE, EMBASE, CINAHL, SCOPUS from 1990 to 2010, and reference lists from included studies was conducted. Two reviewers independently screened for inclusion and assessed study quality. One reviewer extracted the data and a second checked for completeness and accuracy. Results. Among nine studies four reported varied beliefs on whether screening was worthwhile for identifying hazardous alcohol use (physicians: 42%–88%; nurses: 50%–100%). Physicians in three studies were divided on intervention provision (32%–54% in support of intervention provision) as were nurses in two studies (39% and 64% nurses in support of intervention provision). Referral for treatment was identified in two studies as an important part of ED management (physicians: 62% and 97%; nurses: 95%). Other attitudes and beliefs identified across the studies included concern that asking about alcohol consumption would be seen as obtrusive or offensive, and a perceived lack of time and resources available for providing care and referrals. Conclusions. ED staff had varying attitudes towards ED management of patients with hazardous alcohol use. Investigations into improving clinical care for hazardous alcohol use are needed to optimize ED management for these patients.

Substance use and posttraumatic stress disorder symptoms in trauma center patients receiving mandated alcohol screening and brief intervention

In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of college policy targeting integrated substance abuse treatment at trauma centers.

Alcohol misuse and multiple sexual partners

INTRODUCTION

We examine the association between self-reported alcohol misuse and alcohol use within 2 hours of having sex and the number of sexual partners among a sample of African-American and Latino emergency department (ED) patients.

METHODS

Cross-sectional data were collected prospectively from a randomized sample of all ED patients during a 5-week period. In face-to-face interviews, subjects were asked to report their alcohol use and number of sexual partners in the past 12 months. Data were analyzed using multiple variable negative binomial regression models, and effect modification was assessed through inclusion of interaction terms.

RESULTS

The 395 study participants reported an average of 1.4 (standard error = 0.11) sexual partners in the past 12 months, 23% reported misusing alcohol, and 28% reported consuming alcohol before sex. There was no statistically significant association between alcohol misuse and the number of sexual partners; however, alcohol before sex was associated with a larger number of sexual partners in the past year. Moreover, among those who misused alcohol, participants who reported alcohol before sex were 3 times more likely to report a higher number of sexual partners (risk ratio = 3.2; confidence interval [CI] =1.9-5.6). The association between alcohol use before sex and number of sexual partners is dependent upon whether a person has attributes of harmful drinking over the past 12 months. Overall, alcohol use before sex increases the number of sexual partners, but the magnitude of this effect is significantly increased among alcohol misusers.

CONCLUSION

Alcohol misusers and those who reported having more than 1 sexual partner were more likely to cluster in the same group, ie, those who used alcohol before sex. Efforts to reduce the burden of sexually transmitted diseases, including human immunodeficiency virus, and other consequences of risky sexual behavior in the ED population should be cognizant of the interplay of alcohol and risky sexual behaviors. EDs should strive to institute a system for regular screening, brief intervention, and referral of at-risk patients to reduce negative consequences of alcohol misuse, including those of risky sexual behaviors.

Efficacy of an emergency department-based multicomponent intervention for smokers with substance use disorders

The efficacy of brief emergency department (ED)-based interventions for smokers with concurrent alcohol or substance use is unknown. We performed a subgroup analysis of a trial enrolling adult smokers in an urban ED, focusing on subjects who screened positive for alcohol abuse or illicit drug use. Subjects receiving usual care (UC) were given a smoking cessation brochure; those receiving enhanced care (EC) got the brochure, a brief negotiated interview, 6 weeks of nicotine patches, and a telephone call. Follow-up occurred at 3 months. Of 340 subjects in the parent study, 88 (25.9%) reported a substance use disorder. At 3 months, substance users receiving EC were more likely to be tobacco-abstinent than those receiving UC (14.6% versus 0%, p = .015), and to self-identify as nonsmokers (12.5% v. 0%, p = .03). This finding suggests that concurrent alcohol or substance use should not prevent initiation of tobacco dependence treatment in the ED.

Screening for alcohol and drug use disorders among adults in primary care: a review

BACKGROUND: The Patient Protection and Affordable Care Act of 2010 supports integration of substance abuse interventions and treatments into the mainstream health care system. Thus, effective screening and intervention for substance use disorders in health care settings is a priority. OBJECTIVE: This paper reviews the prevalence of alcohol and drug use disorders (abuse or dependence) in primary care settings and emergency departments, as well as current screening tools and brief interventions. METHODS: MEDLINE was searched using the following keywords: alcohol use, alcohol use disorder, drug use, drug use disorder, screening, primary care, and emergency departments. Using the related-articles link, additional articles were screened for inclusion. This review focuses on alcohol and drug use and related disorders among adults in primary care settings. CONCLUSION: Screening, brief intervention, and referral for treatment are feasible and effective in primary care settings, provided that funding for screening is available, along with brief interventions and treatment facilities to which patients can be referred and treated promptly.

A brief intervention reduces hazardous and harmful drinking in emergency department patients

STUDY OBJECTIVE

Brief interventions have been shown to reduce alcohol use and improve outcomes in hazardous and harmful drinkers, but evidence to support their use in emergency department (ED) patients is limited. The use of research assessments in studies of brief interventions may contribute to uncertainty about their effectiveness. Therefore we seek to determine (1) if an emergency practitioner-performed Brief Negotiation Interview or a Brief Negotiation Interview with a booster reduces alcohol consumption compared with standard care; and (2) the impact of research assessments on drinking outcomes using a standard care-no-assessment group.

METHODS

We randomized 889 adult ED patients with hazardous and harmful drinking. A total of 740 received an emergency practitioner-performed Brief Negotiation Interview (n=297), a Brief Negotiation Interview with a 1-month follow-up telephone booster (Brief Negotiation Interview with booster) (n=295), or standard care (n=148). We also included a standard care with no assessments (n=149) group to examine the effect of assessments on drinking outcomes. Primary outcomes analyzed with mixed-models procedures included past 7-day alcohol consumption and 28-day binge episodes at 6 and 12 months, collected by interactive voice response. Secondary outcomes included negative health behaviors and consequences collected by telephone surveys.

RESULTS

The reduction in mean number of drinks in the past 7 days from baseline to 6 and 12 months was significantly greater in the Brief Negotiation Interview with booster (from 20.4 [95% confidence interval {CI} 18.8 to 22.0] to 11.6 [95% CI 9.7 to 13.5] to 13.0 [95% CI 10.5 to 15.5]) and Brief Negotiation Interview (from 19.8 [95% CI 18.3 to 21.4] to 12.7 [95% CI 10.8 to 14.6] to 14.3 [95% CI 11.9 to 16.8]) than in standard care (from 20.9 [95% CI 18.7 to 23.2] to 14.2 [95% CI 11.2 to 17.1] to 17.6 [95% CI 14.1 to 21.2]). The reduction in 28-day binge episodes was also greater in the Brief Negotiation Interview with booster (from 7.5 [95% CI 6.8 to 8.2] to 4.4 [95% CI 3.6 to 5.2] to 4.7 [95% CI 3.9 to 5.6]) and Brief Negotiation Interview (from 7.2 [95% CI 6.5 to 7.9] to 4.8 [95% CI 4.0 to 5.6] to 5.1 [95% CI 4.2 to 5.9]) than in standard care (from 7.2 [95% CI 6.2 to 8.2] to 5.7 [95% CI 4.5 to 6.9] to 5.8 [95% CI 4.6 to 7.0]). The Brief Negotiation Interview with booster offered no significant benefit over the Brief Negotiation Interview alone. There were no differences in drinking outcomes between the standard care and standard care-no assessment groups. The reductions in rates of driving after drinking more than 3 drinks from baseline to 12 months were greater in the Brief Negotiation Interview (38% to 29%) and Brief Negotiation Interview with booster (39% to 31%) groups than in the standard care group (43% to 42%).

CONCLUSION

Emergency practitioner-performed brief interventions can reduce alcohol consumption and episodes of driving after drinking in hazardous and harmful drinkers. These results support the use of brief interventions in ED settings.

Patient preferences for emergency department-initiated tobacco interventions: a multicenter cross-sectional study of current smokers

BACKGROUND

The emergency department (ED) visit provides a great opportunity to initiate interventions for smoking cessation. However, little is known about ED patient preferences for receiving smoking cessation interventions or correlates of interest in tobacco counseling.

METHODS

ED patients at 10 US medical centers were surveyed about preferences for hypothetical smoking cessation interventions and specific counseling styles. Multivariable linear regression determined correlates of receptivity to bedside counseling.

RESULTS

Three hundred seventy-five patients were enrolled; 46% smoked at least one pack of cigarettes per day, and 11% had a smoking-related diagnosis. Most participants (75%) reported interest in at least one intervention. Medications were the most popular (e.g., nicotine replacement therapy, 54%), followed by linkages to hotlines or other outpatient counseling (33-42%), then counseling during the ED visit (33%). Counseling styles rated most favorably involved individualized feedback (54%), avoidance skill-building (53%), and emphasis on autonomy (53%). In univariable analysis, age (r=0.09), gender (average Likert score=2.75 for men, 2.42 for women), education (average Likert score=2.92 for non-high school graduates, 2.44 for high school graduates), and presence of smoking-related symptoms (r=0.10) were significant at the p<0.10 level and thus were retained for the final model. In multivariable linear regression, male gender, lower education, and smoking-related symptoms were independent correlates of increased receptivity to ED-based smoking counseling.

CONCLUSIONS

In this multicenter study, smokers reported receptivity to ED-initiated interventions. However, there was variability in individual preferences for intervention type and counseling styles. To be effective in reducing smoking among its patients, the ED should offer a range of tobacco intervention options.

Sociodemographic and substance use correlates of tobacco use in a large, multi-ethnic sample of emergency department patients

Strong evidence suggests marked disparities among ethnic minorities in relation to tobacco use. To date, a majority of the data available discusses tobacco use in the general population. Using a sample of Latino, non-Latino Black (NLB), and non-Latino White (NLW) patients presenting to the emergency departments, the present study examined sociodemographic and substance use correlates of past 3-month tobacco use. Over 48,000 patients were interviewed as part of a screening and brief intervention program in southern California. Overall, although NLB adults reported the greatest prevalence of tobacco use compared to NLWs and Latinos (43% vs. 34% and 22% respectively), associations between tobacco use, demographics and substance use were similar across groups. Males, younger individuals, those with lower income, and being at higher risk for alcohol and drug use were more likely to report recent tobacco use. Future tobacco interventions in emergency settings should highlight these specific risk factors for Latinos, NLBs, and NLWs.

Preventing disparities in alcohol screening and brief intervention: the need to move beyond primary care

The alcohol treatment field has focused on promoting screening and brief intervention (SBI) in medically based settings, particularly primary care. In this Commentary, we consider the potential unintended consequences for disparities in access to care for alcohol problems. National data show significant racial/ethnic and socioeconomic differences in the rates at which at-risk drinkers and persons with alcohol use disorders come into contact with primary care providers. This suggests that implementing SBI in mostly primary care settings could inadvertently widen the gap in alcohol-related health disparities. To ensure that all populations in need benefit from this evidence-based treatment, SBI should be considered and adapted for a wider range of service venues, including Federally Qualified Health Centers and venues frequented by racial/ethnic minorities and the uninsured.

Ethnoracial differences in emergency department patients' tobacco use

INTRODUCTION

This study examined ethnoracial differences in lifetime and recent tobacco use and related problems in a large convenience sample of Latino, Black, and Non-Latino White emergency department (ED) patients. In addition, ED patients' use rates were compared with those of a statewide sample.

METHODS

Trained bilingual/bicultural health educators screened almost 53,000 ED patients in 8 ED/trauma units throughout San Diego County over a 2-year period. Measures included sociodemographic characteristics and tobacco use measures from the Alcohol, Smoking, and Substance Involvement Screening Test brief screening instrument.

RESULTS

A consistent finding was the lower prevalence of tobacco use among Latino patients compared with Black and Non-Latino White patients. Compared with their general population counterparts, Non-Latino White, Latino, and Black patients were more likely to have used tobacco in their lifetime and on a daily basis.

CONCLUSIONS

Results indicate the high tobacco risk status of ED patients, regardless of ethnicity. More work is needed to develop effective approaches for ED-initiated tobacco interventions for patients in various racial/ethnic groups. Offering tobacco cessation support in opportune venues such as the ED holds great potential to improve accessibility to public health interventions for many underserved communities who may not have regular interaction with a primary care provider.

Instruments to detect alcohol and other drug misuse in the emergency department: a systematic review

CONTEXT

Alcohol and other drug (AOD) misuse by youth is a significant public health concern. Unanticipated treatment for AOD-related morbidities is often sought in hospital emergency departments (EDs). Screening instruments that rapidly identify patients who require further diagnostic evaluation and/or brief intervention are critically important.

OBJECTIVE

To summarize evidence on screening instruments that can assist emergency care clinicians in identifying AOD misuse in pediatric patients.

METHODS

Fourteen electronic databases (including Medline, Embase, and PsycINFO) and reference screening were used. Psychometric and prospective diagnostic studies were selected if the instrument focused on detecting AOD misuse in patients aged 21 years or younger in the ED. Two reviewers independently assessed quality and extracted data. Validity and reliability data were collected for psychometric studies. Instrument performance was assessed by using sensitivity, specificity, and positive (LR(+)) and negative (LR(-)) likelihood ratios. Meta-analysis was not possible because of clinical and measurement heterogeneity.

RESULTS

Of the 1545 references initially identified, 6 studies met inclusion criteria; these studies evaluated 11 instruments for universal or targeted screening of alcohol misuse. Instruments based on diagnostic criteria for AOD disorders were effective in detecting alcohol abuse and dependence (sensitivity: 0.88; specificity: 0.90; LR(+): 8.80) and cannabis use disorder (sensitivity: 0.96; specificity: 0.86; LR(+): 6.83).

CONCLUSIONS

On the basis of the current evidence, we recommend that emergency care clinicians use a 2-question instrument for detecting youth alcohol misuse and a 1-question instrument for detecting cannabis misuse. Additional research is required to definitively answer whether these tools should be used as targeted or universal screening approaches in the ED.

NIH Roundtable on Opportunities to Advance Research on Neurologic and Psychiatric Emergencies

STUDY OBJECTIVE

The Institute of Medicine Committee on the Future of Emergency Care in the United States Health System (2003) identified a need to enhance the research base for emergency care. As a result, a National Institutes of Health (NIH) Task Force on Research in Emergency Medicine was formed to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 Roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. We identify key research questions essential to advancing the science of emergency care and discuss the barriers and strategies to advance research by exploring the collaboration between NIH and the emergency care community.

METHODS

Experts from emergency medicine, neurology, psychiatry, and public health assembled to review critical areas in need of investigation, current gaps in knowledge, barriers, and opportunities. Neurologic emergencies included cerebral resuscitation, pain, stroke, syncope, traumatic brain injury, and pregnancy. Mental health topics included suicide, agitation and delirium, substances, posttraumatic stress, violence, and bereavement.

RESULTS

Presentations and group discussion firmly established the need for translational research to bring basic science concepts into the clinical arena. A coordinated continuum of the health care system that ensures rapid identification and stabilization and extends through discharge is necessary to maximize overall patient outcomes. There is a paucity of well-designed, focused research on diagnostic testing, clinical decisionmaking, and treatments in the emergency setting. Barriers include the limited number of experienced researchers in emergency medicine, limited dedicated research funding, and difficulties of conducting research in chaotic emergency environments stressed by crowding and limited resources. Several themes emerged during the course of the roundtable discussion, including the need for development of (1) a research infrastructure for the rapid identification, consent, and tracking of research subjects that incorporates innovative informatics technologies, essential for future research; (2) diagnostic strategies and tools necessary to understand key populations and the process of medical decisionmaking, including the investigation of the pathobiology of symptoms and symptom-oriented therapies; (3) collaborative research networks to provide unique opportunities to form partnerships, leverage patient cohorts and clinical and financial resources, and share data; (4) formal research training programs integral for creating new knowledge and advancing the science and practice of emergency medicine; and (5) recognition that emergency care is part of an integrated system from emergency medical services dispatch to discharge. The NIH Roundtable "Opportunities to Advance Research on Neurological and Psychiatric Emergencies" created a framework to guide future emergency medicine-based research initiatives.

CONCLUSION

Emergency departments provide the portal of access to the health care system for most patients with acute neurologic and psychiatric illness. Emergency physicians and colleagues are primed to investigate neurologic and psychiatric emergencies that will directly improve the delivery of care and patient outcomes.

Manejo do paciente com transtornos relacionados ao uso de substância psicoativa na emergência psiquiátrica

OBJETIVO: Transtornos por uso de substâncias são prevalentes em setores de emergência gerais e psiquiátricos, atingindo taxas de 28% das ocorrências em prontos-socorros gerais. Todavia, profissionais dos setores de emergência identificam menos que 50% dos casos de problemas relacionados ao álcool. Este artigo visa fornecer base fundamentada em evidências para o tratamento específico a pacientes que preencham os critérios diagnósticos de transtornos por uso de substâncias e que se apresentam ao pronto-socorro em quadros de intoxicação ou abstinência. MÉTODO: Uma revisão sobre o tema foi realizada na base de dados Medline, usando-se os descritores "intoxicação aguda", "abstinência", "álcool", "cocaína", "cannabis", "opioides", "inalantes" e "manejo", tendo o inglês como idioma. RESULTADOS E CONCLUSÃO: O cuidado de pessoas com transtornos por uso de substâncias deve conter: avaliação completa (médica geral e psiquiátrica), tratamento dos quadros diagnosticados (abstinência, intoxicação e quadros clínicos que caracterizem uma emergência), sensibilização do paciente para realizar tratamento, se for necessário, e elaboração de encaminhamento.

A brief motivational interview in a pediatric emergency department, plus 10-day telephone follow-up, increases attempts to quit drinking among youth and young adults who screen positive for problematic drinking

OBJECTIVES

Adolescents in their late teens and early 20s have the highest alcohol consumption in the United States; binge drinking peaks at age 21-25 years. Underage drinking is associated with many negative consequences, including academic problems and risk of intentional and unintentional injuries. This study tested the effectiveness of pediatric emergency department (PED) screening and brief intervention to reduce alcohol consumption and associated risks.

METHODS

A three-group randomized assignment trial was structured to test differences between intervention (I) and standard assessed control (AC) groups in alcohol consumption and alcohol-related behaviors from baseline to 12 months and to compare the AC group with a minimally assessed control (MAC) group to adjust for the effect of assessment reactivity on control group behavior. Patients aged 14-21 years were eligible if they screened positive on the Alcohol Use Disorders Identification Test (AUDIT) or for binge drinking or high-risk behaviors. The MAC group received a resource handout, written advice about alcohol-related risks, and a 12-month follow-up appointment. Patients in the AC group were assessed using standardized instruments in addition to the MAC protocol. The I group received a peer-conducted motivational intervention, referral to community resources and treatment if indicated, and a 10-day booster in addition to assessment. Measurements included 30-day self-report of alcohol consumption and alcohol-related behaviors, screens for depression and posttraumatic stress disorder, and self-report of attempts to quit, cut back, or change conditions of use, all repeated at follow-up. Motor vehicle records and medical records were also analyzed for changes from baseline to 1-year follow-up.

RESULTS

Among 7,807 PED patients screened, 1,202 were eligible; 853 enrolled (I, n = 283; AC, n = 284; MAC, n = 286), with a 12-month follow-up rate of 72%. At 12 months, more than half of enrollees in Reaching Adolescents for Prevention (RAP) attempted to cut back on drinking, and over a third tried to quit. A significantly larger proportion of the I group made efforts to quit drinking and to be careful about situations when drinking compared to AC enrollees, and there was a numerically but not significantly greater likelihood (p = 0.065) among the I group for efforts to cut back on drinking. At 3 months, the likelihood of the I group making attempts to cut back was almost triple that of ACs. For efforts to quit, it was double, and for trying to be careful about situations when drinking, there was a 72% increase in the odds ratio (OR) for the I group. Three-month results for attempts were sustained at 12 months for quit attempts and efforts to be careful. Consumption declined in both groups from baseline to 3 months to 12 months, but there were no significant between-group differences in alcohol-related consequences at 12 months or in alcohol-related risk behaviors. We found a pattern suggestive of assessment reactivity in only one variable at 12 months: the attempt to cut back (73.3% for the I group vs. 64.9% among the AC group and 54.8% among the MAC group).

CONCLUSIONS

Brief motivational intervention resulted in significant efforts to change behavior (quit drinking and be careful about situations while drinking) but did not alter between-group consumption or consequences.

Emergency medicine public health research funded by federal agencies: progress and priorities

The emergency department (ED) visit provides an opportunity to impact the health of the public throughout the entire spectrum of care, from prevention to treatment. As the federal government has a vested interest in funding research and providing programmatic opportunities that promote the health of the public, emergency medicine (EM) is prime to develop a research agenda to advance the field. EM researchers need to be aware of federal funding opportunities, which entails an understanding of the organizational structure of the federal agencies that fund medical research, and the rules and regulations governing applications for grants. Additionally, there are numerous funding streams outside of the National Institutes of Health (NIH; the primary federal health research agency). EM researchers should seek funding from agencies according to each agency's mission and aims. Finally, while funds from the Department of Health and Human Services (HHS) are an important source of support for EM research, we need to look beyond traditional sources and appeal to other agencies with a vested interest in promoting public health in EDs. EM requires a broad skill set from a multitude of medical disciplines, and conducting research in the field will require looking for funding opportunities in a variety of traditional and not so traditional places within and without the federal government. The following is the discussion of a moderated session at the 2009 Academic Emergency Medicine consensus conference that included panel discussants from the National Institutes of Mental Health, Drug Abuse, and Alcoholism and Alcohol Abuse and the Centers for Disease Control and Prevention (CDC). Further information is also provided to discuss those agencies and centers not represented.