Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work?

Implementing an effective intervention for problem drinkers on medical wards

Many medical inpatients have alcohol related problems but evidence of the feasibility of instituting a brief intervention is incomplete. An alcohol counsellor trained nurses on five general medical wards to screen patients routinely for alcohol problems. She counselled appropriate patients using one or two counselling sessions. Efficacy of the counselling was assessed at interview six months following the admission. We found that 19.6% of male and 4.8% of female medical patients were drinking more than 50 units (U) or 33 drinks per week (male) or 35 U or 23 drinks per week (female). Counselling, with one or two sessions led to a reduction from a median of 74 U (49 drinks) per week at admission to 26 U (17 drinks) per week at six months follow-up. A second counselling session after discharge showed no advantage over a single one administered while the patient was in the ward. The barriers to developing a successful alcohol screening and counselling service in medical wards can be overcome provided there is also adequate support and training of the ward nursing staff.

Trauma patient willingness to participate in alcohol screening and intervention

BACKGROUND

Screening and brief interventions for alcohol disorders in the trauma setting are not routine. Perceived barriers to screening and treatment include the perception that patients find the topic offensive and the feasibility of screening all patients. The hypothesis of the study was that discussing alcohol use would be acceptable to patients independent of race or screening test score. Additional aims were to describe whether patients had access to alcohol screening via a primary care physician, to see what types of treatment patients thought appropriate, and to evaluate the feasibility of screening all trauma patients for alcohol disorders.

METHODS

We surveyed 150 trauma inpatients regarding the offensiveness of discussing alcohol use and the appropriateness of different treatment options. We asked whether they had access to a primary care physician. As part of our routine screening program, we evaluated the proportion of patients we were able to screen with the Alcohol Use Disorders Identification Test, refusal rates, and whether any patients were not screened. Analysis of covariance and logistic regression were used to evaluate responses.

RESULTS

A part-time research assistant approached 90% of 163 patients. Seventy percent were successfully screened, of which 45% screened positive for problematic alcohol use. Of the patients we were unable to screen, one third did not speak English and one half had injuries precluding interaction, leaving 16 patients (9.8%) that were "missed." One patient (<1%) refused screening. One hundred fifty consecutive patients participated in the survey. The ethnic distribution was 26% Native American, 40% Hispanic, 30% white, 2% African American, and 2% other. A brief counseling session was acceptable to all ethnic groups. There were ethnic differences in acceptability of other types of treatment. Ninety-four percent of patients thought that somebody from the trauma team should talk with patients about alcohol. Alcohol Use Disorders Identification Test score did not predict whether patients would be offended (p = 0.48). Forty-five percent had a primary care physician and only 10% had ever spoken to their physician about alcohol use.

CONCLUSION

The majority of trauma patients are not offended by discussing alcohol use while hospitalized for injury and can feasibly be screened for alcohol disorders. Treatment types may need to be culturally tailored.

Primary care: is there enough time for prevention?

OBJECTIVES

We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel.

METHODS

We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population.

RESULTS

To fully satisfy the USPSTF recommendations, 1773 hours of a physician's annual time, or 7.4 hours per working day, is needed for the provision of preventive services.

CONCLUSIONS

Time constraints limit the ability of physicians to comply with preventive services recommendations.

Randomized controlled trial on the effects of a skills-based workshop on medical students' management of problem drinking and alcohol dependence

The purpose of this study was to determine whether a skills-based workshop will improve medical students' management of problem drinking and alcohol dependence in simulated patients. Seventy-six 3rd and 4th year Ontario medical students were randomized to receive a 3-h workshop on either problem drinking and alcohol dependence or depression (control condition). Students then completed eight simulated office visits (OSCE stations) with simulated patients presenting with depression, problem drinking or alcohol dependence. Examiners completed a checklist of the questions asked and advice given by the student, and simulated patients and examiners completed a global rating scale. Four months later, students were sent a survey on their knowledge, attitudes, and behavior towards patients with alcohol problems. The alcohol group received significantly higher assessment and management checklist scores and global rating scores than did the depression group (p < 0.01) and performed better on almost all aspects of clinical management of both problem drinking and alcohol dependence. On the follow-up survey (n = 55) the alcohol group showed a significant increase in beliefs about self-efficacy in managing alcohol problems (p < 0.05) and had greater knowledge of reduced drinking strategies, but the two groups did not differ on other measures. A skills-based workshop causes marked short-term improvements in medical students' management of problem drinking and alcohol dependence, an increase from baseline to postworkshop in self-efficacy beliefs that was sustained through to follow-up, and greater knowledge of reduced drinking strategies. Repeated reinforcement of clinical skills may be required for a long-term impact on clinical behavior.

Identification and brief treatment of alcohol problems with medical patients: an international perspective

This article summarizes the proceedings of a symposium at the 2002 RSA meeting in San Francisco, California. The chair was Peter Monti and co-chair was Nancy Barnett. The aim of the symposium was to bring together researchers from the United States, Sweden, and Mexico to present current findings on the development and implementation of screening and intervention research in Emergency Departments (ED). Cheryl Cherpitel presented findings on the performance of the Rapid Alcohol Problems Screen (RAPS4), a 4-item instrument used for screening for alcohol dependence and harmful drinking in the ED. Dr. Cherpitel also presented for her collaborator, Guilherme Borges, their research on the performance of a number of screening measures including the RAPS among Mexicans and Mexican-Americans with alcohol-related disorders in the ED. Preben Bendtsen described the implementation of an alcohol screening and intervention procedure delivered by ordinary ED staff in Sweden. Nancy Barnett presented data on characteristics related to readiness to change alcohol use in a sample of young adults who were treated in an ED for injury or intoxication.

Physician advice about smoking and drinking: are U.S. adults being informed?

BACKGROUND

Population-based estimates for the prevalence of smokers receiving advice from a health professional to quit smoking and the prevalence of binge drinkers being talked to about alcohol use are lacking for U.S. adults. This information is useful for clinicians and public health professionals.

METHODS

Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digit-dial telephone survey of U.S. adults. In 1997, 10 states collected data on these health interventions for tobacco and alcohol use. The prevalence of professional advice to quit smoking and about alcohol use was calculated and examined by demographic characteristics. The number of at-risk adults who had a routine checkup in the last year and had not received these interventions was also estimated.

RESULTS

By self-report, 70% of smokers were advised to quit, and 23% of binge drinkers were talked to about their alcohol use. Using multivariate logistic regression analyses, we found among smokers that women and older persons were more likely to receive advice; among binge drinkers, health intervention was more likely to occur for men and non-Hispanic blacks. Across the 10 states, approximately 2 million smokers and 2 million binge drinkers with a routine checkup in the past 12 months were not advised to quit smoking or talked to about their alcohol use.

CONCLUSIONS

Many opportunities to intervene with smokers and binge drinkers are lost. Efforts to increase physician education and to identify and reduce other barriers may help.

A randomized trial of a brief alcohol intervention for needle exchangers (BRAINE)

AIMS

To test motivational interviewing (MI) as a brief intervention for reducing alcohol use among needle exchange clients.

DESIGN

Randomized clinical trial.

SETTING

Needle exchange program-Providence, Rhode Island, USA.

PARTICIPANTS

Between 2/98 and 10/99, we recruited 187 AUDIT-positive (>8) active injection drug users.

INTERVENTION

Those assigned to a brief motivational intervention (MI) condition received two 1-hour therapist sessions following assessment visits, 1 month apart, focusing on alcohol use and HIV risk-taking.

MEASUREMENTS

Control and MI subjects received identical research assessments at baseline, 1 and 6 months following study enrollment. At 6 months, study outcomes included days of alcohol use measured using the time-line follow-back method.

FINDINGS

Study retention was 96.8% at 6 months. Participants reported an average of 12.0 drinking days at baseline and 8.3 at 6 months. Significant reductions in drinking days were observed in both treatment conditions. We found significant treatment x baseline drinking day interaction effects. Tests for simple main effects were significant for subjects with above median (>9) baseline drinking day frequency, but not for those with below median baseline drinking frequency. Comparisons on dichotomous outcomes provided supporting evidence of treatment efficacy; those in MI were over two times more likely than controls to report reductions of 7 days or more (P < 0.05).

CONCLUSIONS

This study provides the first direct evidence that brief MI can decrease alcohol use among active injection drug users with drinking problems. Heavier drinkers seem best suited for this intervention, but the optimal intensity of treatments and which components of brief intervention are most effective deserve further study.

Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking

OBJECTIVE

This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared.

DESIGN

Cross-sectional analyses of audiotaped appointments collected over 6 months.

PARTICIPANTS AND SETTING

Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients ( N = 47) and providers ( N = 17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus.

INTERVENTION

Intervention providers received patient-specific results of positive alcohol-screening tests at each visit.

MEASURES AND MAIN RESULTS

Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected "resistance" to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P =.026).

CONCLUSIONS

During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted.

Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations

Brief interventions for alcohol use disorders have been the focus of considerable research. In this meta-analytic review, we considered studies comparing brief interventions with either control or extended treatment conditions. We calculated the effect sizes for multiple drinking-related outcomes at multiple follow-up points, and took into account the critical distinction between treatment-seeking and non-treatment-seeking samples. Most investigations fell into one of two types: those comparing brief interventions with control conditions in non-treatment-seeking samples (n = 34) and those comparing brief interventions with extended treatment in treatment-seeking samples (n = 20). For studies of the first type, small to medium aggregate effect sizes in favor of brief interventions emerged across different follow-up points. At follow-up after > 3-6 months, the effect for brief interventions compared to control conditions was significantly larger when individuals with more severe alcohol problems were excluded. For studies of the second type, the effect sizes were largely not significantly different from zero. This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals to non-treatment-seeking samples. The results concur with previous reviews that found little difference between brief and extended treatment conditions. Because the evidence regarding brief interventions comes from different types of investigation with different samples, generalizations should be restricted to the populations, treatment characteristics and contexts represented in those studies.

Screening and brief interventions for alcohol use disorders in managed care settings

This chapter will focus on the identification and treatment of alcohol use disorders in general medical care settings in the context of managed care systems. The chapter will include the best data available on the prevalence of problem drinking, screening procedures, brief intervention ("talk therapy"), and implementation in managed care environments. The clinical protocols presented were designed for primary care clinicians working with patients seeking routine medical care. The protocol was developed for the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Physicians' Guide. The four steps were designed to help clinicians to screen, to conduct a brief assessment, to provide advice and or referral and to establish follow-up procedures.

A brief intervention for hazardous drinkers in a needle exchange program

Active injection drug users (IDUs) who are also hazardous alcohol users are at particularly high risk for HIV transmission due to sharing of injection equipment. We recruited AUDIT-positive injectors from the Providence, RI needle exchange program for a randomized clinical trial testing the effect of a brief motivational intervention (MI) on frequency of injection-related HIV risk behavior (IRRB). HIV drug risk behavior was measured as the number of days on which subjects reported sharing works using the 30-day Timeline Followback Method. Overall, 109 subjects reported a mean reduction of IRRB days of 9.1 days from baseline to 6-month follow-up (p <.001). When compared to controls, there was a trend in reduction of IRRB days to zero at follow-up for MI subject (OR = 2.1; 95% CI = 0.9-4.5), and strongly significant reductions in IRRB days across a range of alternative improvement thresholds. Results from this study demonstrate that MI reduces drug-related HIV risk behaviors among active IDUs. As a brief intervention, MI may be a useful adjunct to existing services intended to reduce harm.

Detection and diagnosis of psychiatric disorders in primary medical care settings

Research efforts accelerated in the 1990s to define the presentation of common psychiatric disorders in primary care settings. Two diagnostic instruments, the DSM-IV-PC and the PRIME-MD, were introduced in 1994, and a self-report form of the PRIME-MD, the PHQ, was published in 1999. These tools have streamlined the larger, often cumbersome psychiatric nomenclature of the DSM-III and DSM-IV and appear to be more useful in general medical settings. It still is not practical to use either instrument in its entirety for all patients in a busy primary care practice. Studies have suggested an efficient and effective, two-step method of screening primary care patients for psychiatric disorders, however. In this approach, a limited number of probing questions extracted from the PRIME-MD or PHQ (or DSM-IV-PC) are posed to patients, either in person or by a written self-report (i.e., a general health update or review of systems). Then a follow-up evaluation is done to confirm or refute positive screening results. Short, simple questionnaires that address specific topics (e.g., CAGE for alcohol screening or the GDS for mood disorders in older adults) complete and complement this approach. This method has the advantage of being easy to incorporate into routine office practice using minimal physician or office staff time, while showing acceptable sensitivity and specificity in studies to date. More research, particularly prospective studies, is needed to confirm the effectiveness of this approach and expand it beyond the few available studies that have focused mostly on depressive disorders.

Provider education to promote implementation of clinical practice guidelines

STUDY OBJECTIVES

Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education.

METHODS

Experience and data from relevant randomized clinical trials within an educational framework are reviewed.

OBSERVATIONS

Implementation of clinical practice guidelines requires a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice. In addition to physicians, education must be directed at nonphysician clinicians, office staff, and administrators who also are responsible for guideline implementation.

CONCLUSIONS

To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving.

Training Community-Based Clinicians in Screening and Brief Intervention for Substance Abuse Problems: Translating Evidence into Practice

Screening and brief intervention in general health care settings are efficacious but have not been widely adopted. Our objective was to assess the effect of an educational intervention on clinicians' substance abuse-related clinical practices. The study was a telephone survey of practicing physicians, nurses, psychologists, physician's assistants, and social workers who attended a half-day continuing education course on one of four occasions. The course covered the stages of behavioral change and motivational counseling, using primarily role play with standardized patients. Of 87 course attendees, 70 (80%) completed the interview. Months to years after the course, most (91%) reported that the course made an impact on their practice. Most (78%) of respondents reported that they frequently or always asked new patients who drank alcohol a formal screening questionnaire such as the CAGE, and 94% frequently or always assessed their substance abusing patients' readiness to change. Most respondents reported that since taking the course they were more likely (1) to screen patients for alcohol or drug related problems (86%) and (2) to ask patients about their substance abuse on a follow-up visit (96%). After exposure to an active-learning half-day continuing education course, clinicians reported improvement with and high rates of desirable substance abuse-related clinical practices up to 5 years later. Continuing education efforts that incorporate active learning directed toward practicing clinicians show promise for improving rates of brief intervention for alcohol and other drug abuse.