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The Society of Trauma Nurses believes:

 

* Alcohol abuse screenings and brief behavioral counseling interventions (SBIs) should be done in emergency departments and trauma centers to identify at-risk patients for morbidity and mortality related to their alcohol consumption.

 

* The Uniform Policy Provision Law, which allows insurers to refuse to pay medical costs for patients injured while under the influence, should be repealed in all states.

 

* Alcohol screening and alcohol education should be integrated into curricula, continuing education, and standards for all healthcare professionals.

 

* Nurses should participate in collaborative research, education, and data gathering to improve the care of patients with alcohol use problems.

 

 

The US Preventive Services Task Force has suggested guidelines, based on numerous data sources, to help reduce risky/harmful alcohol use by adults.1 Their public health approach would include screening and brief behavioral counseling interventions (SBIs) in primary care settings that would identify patients whose alcohol consumption does not meet criteria for alcohol dependence, but places them at risk for morbidity and mortality. These brief interventions can be as short as 5 minutes and often incorporate 6 elements summarized by the acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy.2 It is hoped, based on these studies, that future research would include implementing these strategies into the practice of routine healthcare.

 

The history of research in this area can easily date back 3 decades ago with the publication of the landmark Accidental Death and Disability in 1970,3 that was the precursor to significant advances in development of trauma centers and their systems in the management of patients with severe injuries. In contrast, those clinicians who treat those injured in alcohol-related events do very little to disrupt one of the major pathways to traumatic injury -- the abuse of alcohol and drugs. Trauma centers are in a unique position to implement screening programs that would also include intervention and referral to appropriate agencies. The tendency not to intervene includes physician training that focuses primarily on critical care management of the trauma patient, an aversion to behaviors of intoxicated patients, limited resources, and assuming that the intoxicated episode is a spurious episode, not a marker of an underlying problem.4

 

Two decades of evidence supports effectiveness of brief interventions that includes 40 controlled studies. Meta-analysis of 12 randomized controlled trials showed that those receiving brief interventions were twice as likely to have moderated their drinking at 6 to 12 months postintervention as those who did not receive any intervention.5 Other studies on the success of screening and brief interventions include a recent evidence-based review that revealed 39 published studies that included 30 randomized controlled and 9 cohort studies. A positive effect was demonstrated in 32 of these studies.6

 

Besides the primary care setting, emergency departments also offer a potential "teaching moment" to those patients who have experienced a negative consequence to their alcohol problem.7,8 Cherpitel9 found that emergency department patients were one and a half to three times more likely to report heavy drinking, alcohol dependence, and consequences of past drinking than those patients in a primary care setting. Project ASSERT, an emergency department- based intervention to increase access to primary care, preventive services, and substance abuse treatment systems, found that 50% of patients with alcohol and drug dependence reported follow-up with the treatment referral.10 A 2001 study by D'Onofrio et al,6 using Project ASSERT, reported similar positive results.

 

Screening tools recommended by the National Institute of Alcohol Abuse and Alcoholism include the use of quantity and frequency questions as well as the CAGE questionnaire. The quantity and frequency questions can determine if the responses exceed the "moderate" drinking levels and are therefore "at risk" for illness and injury. The CAGE questions are better for determining dependence and for those patients who present intoxicated, because it eliminates the need to ask the patient to quantify their drinking, which can be met with resistance.11 Other screening tools used in the detention of alcohol-dependent individuals include the MAST, TWEAK, and the TACE and the FAST.

 

Benefit-cost analysis studies of brief interventions have been few and the methods of conducting the analysis have been inconsistent because brief interventions are not homogeneous entities. The interventions vary in length, structure, targets, and personnel involved. Clearer delineation of the intervention design can alleviate this problem. One study within a managed care setting estimated that for every $10,000 spent on brief interventions for alcohol or drug abuse, $13,500 to $25,000 is saved in medical care spending.12 This study, the first quantitative one, was based on the baseline, 6-month, and 12-month follow-up data from Project TREAT in Wisconsin. The study found a decreased use of ERD and inpatient hospitalizations at savings of $195,000 and a decrease in crime and motor vehicle crashes amounting to $228,000. The total benefit was equal to $1,151 per study patient. In determining the benefits relative to costs, the total cost of the intervention was $80,000, or $205/subject. The net benefit was $947 per study patient. The benefit-cost ratio was equivalent to $56,263 in benefits for every $10,000 spent on the brief intervention.

 

REFERENCES

 

1. Whitlock EP, Polen MR, Green CA et al. US Preventive Services Task Force. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2004;140(7):557-568. [Context Link]

 

2. D'Onofrio G, Bernstein PA, Craig SA, Zink BJ. Patients with Alcohol Problems in the Emergency Department, Part 2: Intervention and Referral. Acad Emerg Med. 1998;5:1210-1217. [Context Link]

 

3. Division of Medical Sciences, National Academy of Sciences, National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. Rockville, MD: US Department of Health, Education and Welfare; 1970. Public Health Service Publication, 1071-A-13. [Context Link]

 

4. Soderstrom CA, Cole FJ, Porter JM. Injury Control and Violence Prevention Committee. Injury in America: The Role of Alcohol and Other Drugs -An EAST Position Paper Prepared by the Injury Control and Violence Prevention Committee. J Trauma. 2001;50:1-12. [Context Link]

 

5. Screening patients for alcohol, tobacco, and other drug misuse: the role of interventions. West J Med. 2000;172(1):53-57. [Context Link]

 

6. D'Onofrio G, Mascia R, Razzak J, Degutis LC. Utilizing health promotion advocates for selected health risk screening and intervention in the emergency department. Acad Emerg Med. 2001;8:543. [Context Link]

 

7. Longabaugh R, Minugh PA, Nirenberg TD et al. Injury as a motivator to reduce drinking. Acad Emerg Med. 1995;2:817-825. [Context Link]

 

8. Cherpetel CJ. Drinking patterns and problems and drinking in the event: an analysis of injury by cause among casualty patients. Alcohol Clin Exp Res. 1996;20:1130-1137. [Context Link]

 

9. Cherpitel CJ. Drinking patterns and problems: a comparison of primary care within the emergency room. Subst Abuse. 1997;20:85-95. [Context Link]

 

10. Bernstein E, Bernstein J, Levenson S. Project ASSERT-an emergency department based intervention to increase access to primary care, preventive services and the substance abuse treatment system. Ann Emerg Med. 1997;30:181-189. [Context Link]

 

11. Cherpitel CJ. Screening for alcohol problems in the emergency department. Ann Emerg Med. 1995;26:158-166. [Context Link]

 

12. Fleming M, Mundt MP, French MT et al. Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care. 2000;38(1):7-18. [Context Link]