Alcohol and Tobacco Screening, Brief Intervention, Referral and Treatment (SBIRT) for Emergency Room Patients

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Alcohol and Tobacco Screening, Brief
Intervention, Referral and Treatment (SBIRT) for
Emergency Room Patients

• Mary K. Murphy, Ph.D.1
• David Lounsbury, Ph.D. 2
• Albert Einstein College of Medicine
• Department of Emergency Medicine1, 2
• Epidemiology and Population Health1
• Tobacco Think Tank Meeting 10/12/10

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purpose
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A Major Public Health Problem

• Alcohol and tobacco are among the most widely
  used addictive drugs
• Both contribute significantly to preventable
  morbidity and mortality
• Co-use of alcohol and tobacco further heightens
  the risk of disease and death
• Alcohol consumption ? injuries and deaths from
  motor vehicle accidents, falls, drowning, fires
  and burns, and violence
• Tobacco consumption ? 1 cause of preventable
  morbidity and mortality in US

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Rationale for Integrated Treatment Services

• Among at-risk and dependent drinkers, smoking
  prevalence is about 70 compared to 24 for
  non-smokers
• People who drink are 3x more likely to smoke
• Alcohol consumption has been identified as a
  trigger for smoking and relapse to smoking
• Highest risk group- multiplicative risk increase,
  possible biological synergy

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Uncertainty about Combined Treatment Strategies

• We dont know how much of what kind of treatment
  for which kind of co-user will work
• What do patients want to address first? Their
  alcohol or tobacco use?
• How much of what kind of treatment (counseling
  and/or pharmacotherapy) is needed to reduce their
  drinking to a safe level? Or to quit smoking?
• Phone, face-to-face, e-mail/texting, a
  combination. What modality is most effective?
• How does gender, race, ethnicity, age, years of
  use and/or dependency matter?

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Proposed Specific Aims
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• Aim 1 Identify and modify existing treatment
  manuals for motivational counseling interventions
  to be used with a diverse group of ED patients
  who are current smokers and or at-risk drinkers,
  eliciting feedback from experts in the fields of
  motivational interventions and emergency
  medicine, research staff and study participants.

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• Aim 2a Utilize a computer-based screening
  program to assess the prevalence and severity of
  alcohol and tobacco use among a diverse, urban
  population during an emergency department visit.

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• Aim 2b Evaluate the delivery of a brief
  intervention for at risk alcohol users and
  smokers initiated during an ED visit followed by
  telephone counseling conducted over a 2 month
  period post emergency department visit.

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Context
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Emergency Dept Patients Profile

• High prevalence of unmet substance abuse
  treatment need among adult ED patients (Rockett,
  2005)
• 1.5 - 3.0 times more likely to report heavy
  drinking than primary care patients (Cherpitel,
  1999)
• Between 9 and 46 of ED patients have recently
  consumed alcohol and a significant number of the
  32 million ED injury visits are alcohol-related
  (Bernstein, E., 1997)
• Approximately 25 use tobacco 12 are at-risk
  drinkers and smoke (Murphy pilot project)

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Methodological approach

• SBIRT (SAMHSA public health approach)
• Comprehensive brief intervention approach that
  delivers early intervention and treatment
  services to people with substance use disorders
  and people who are at-risk of developing these
  disorders
• Goal ? early intervention with at-risk substance
  users before more severe consequences occur

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Screening, Brief Intervention, Referral
Treatment (SBIRT) Goals

• NIAAA safe drinking guidelines
• PHS guideline for treating tobacco use and
  dependence (5As and 5Rs)
• Apply standardized screening instruments
• Provide
• Normative feedback
• Treatment resources when indicated (i.e., above
  safe drinking limits and/or currently using
  tobacco)

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Prior SBIRT Research

• A recent systematic review of 39 SBIRT alcohol
  studies (predominantly RCTs) targeting alcohol
  users found that such interventions are effective
  in facilitating significant reductions in alcohol
  consumption (DOnofrio Degutis 2002)
• Challenge SBIRT most effective with primary care
  pts, ED injury pts, decrease neg consequences
  assoc drinking such as DUI- inconsistent alc
  reductions w/in ED pop (Havard et al 2008). Why?
• Studies note computers should be utilized in
  SBIRT interventions (Hungerford Pollock , 2003
  Bernstein, SL et al 2007)

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CASI Pilot

• Cross sectional design
• Bilingual RAs 24/7 ED coverage
• Medically stable, gt 1 hr since triage, AO X3, gt
  21 yo, No SI/HI, informed consent, no gross
  intoxication, pass computer screen
• Computer program provided by Boston University
  School of Public Health / Join Together
  syndicated website (www.alcoholscreening.org) Eng
  / Span
• AUDIT, normative feedback, alcohol education,
  treatment referral, debriefing session (10-15 min)

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METHODS
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R21 Proposed Design

• Computer assisted self interview (CASI) in ED
• Motivational interviewing (MI) counseling
  intervention in ED by MA level counselor (goal
  to encourage treatment engagement promote
  reduction in drinking / smoking)
• 2 month follow up period
• Timepoints In ED (in person) followed by 2
  weeks, 1 month and 2 months post ED (phone)

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Staffing, Training and Supervision

• Bilingual Research Assistants staff ED 24/7 will
  complete baselines follow up assessments
• Two trained Masters Level study therapists will
  be hired to conduct MI phone counseling sessions
• BNI-ART Institute at Boston University will
  provide therapist training
• Audio taped counseling sessions will be reviewed
  for reliability protocol fidelity

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CASI Instruments and MI Assessment Guides

• Emergency Room Patient Demographics
• General Health (Questionnaire)
• Alcohol Use Disorders Identification Test
• Fagerstrom Test for Nicotine Dependence
• CASI Satisfaction (Questionnaire)
• Who, What, When, Where Why (5Ws) Questionnaire
• Medical Problems and Prior Treatment
  Questionnaire

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Proposed Recruitment Strategy

• Approach approximately n1,000 ED patients
• Identify approx 120 alc / tob co-users (our main
  interest)
• Possible designs
• Randomize half patients to MI intervention
• Deliver intervention to ALL patients no control
  group
• Alternate multifactorial design Alc only, Tob
  only, Alctob no interv (different from all of
  the above, allows for multiple comparisons
  doubles the sample size)

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Outcomes/Endpoints

• Alcohol Past 30 days mean number of standard
  drinks per week drinking within NIAAA
  guidelines change in stage of change
• Tobacco Number of quit attempts smoking status
  change in stage of change
• Community service access Number of services
  contacted number of contacts per service
  satisfaction with services received

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Addressing Reviewer comments
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Does it make clinical sense to combine these two
interventions?

• Proposed treatment has already demonstrated
  less than sufficient effectiveness in smokers in
  the ED, there is not a compelling case made in
  the grant that combining the 2 interventions for
  one multiply-diagnosed population will be more
  effective than the mono therapy

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Aims are too ambitious

• First 2 aims are feasible but third aim of
  conducting an RCT is overreaching, timeline does
  not allow for 5 follow ups.
• R21 Encourages new, exploratory and
  developmental research projects by providing
  support for the early stages of project
  development.  Sometimes used for pilot and
  feasibility studies.

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