OfficeBased Prevention and Treatment, Part II: Brief Intervention Treatment

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Office-Based Prevention and Treatment, Part
IIBrief Intervention Treatment
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Objectives

• Participants will
• be able to state the efficacy of brief
  intervention methods for the treatment of alcohol
  use disorders
• be able to list the indications and adverse
  effects of brief intervention treatment
• be able to list the indications and adverse
  effects of specialized alcohol treatment
  procedures
• perform brief intervention in a role play
  situation

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What We Know About Brief Intervention...

• Decreases alcohol use in both men and women
• Decreases health care utilization
• Decreases costs
• 1 - 4 sessions are effective
• Physicians can be trained to conduct brief
  interventions

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What We Dont Know About Brief Intervention...

• Key components
• Effectiveness among racial groups
• Efficacy with alcoholics
• Long-term effects on morbidity and mortality

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Treatment Works

• Brief intervention techniques
• At-risk and problem drinkers
• 10-30 reduction at 12 months

• Specialized treatment approaches
• Alcohol dependence
• 5-year abstinence varies

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Steps for Alcohol Screening Brief Intervention
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Randomized Trials of Brief Intervention

• Kristenson (1983)
• Wallace Haines (1988)
• Anderson Scott (1990)
• Babor Saunders (1992)
• Fleming Barry (1997)

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Results of Randomized Trials

• Lower self-reported consumption
• Lower GGT levels
• Better work performance
• Decreased hospitalizations
• Decreased emergency room visits

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Malmo Trial (Kristenson, 1983)
History of trial Public health (1977) Site
Malmo, Sweden Sample Males born
1926-1933 76 participated in health
screening Selection criteria GGT upper 10
(6.6 of total sample) Procedures
Assessment cardiac, diabetes,
alcohol use Intervention
Physician/nurse-delivered, brief Outcome
measures GGT, sick days, inpatient days
24, 48, 60 mos
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Malmo Trial (Kristenson, 1983)
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MRC Trial (Wallace Haines, 1988)
History of trial MRC hypertension trial (1984)
Site 47 GP offices in England
Scotland Sample GP patient list (25 returned
HSQ) Selection criteria q/f - 35 21 units
previous 7 days Procedures Mailed
screening/on-site assessment/ randomization Int
ervention Physician-delivered Outcome
meas. Alcohol use, GGT, alcohol problems 6 and
12 mos
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MRC Trial (Wallace Haines, 1988)
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WHO Trial (Babor Grant, 1992)
History of trial WHO-initiated (1986) Site 8
countries inpatient, emergency room, college,
public health, outpatient Sample Dependent on
country Selection criteria Quantity/frequency Pro
cedures Screening/on-site assessment/randomized
Intervention Health care worker-delivered,
brief Outcome meas. Alcohol use, problems 6 mos
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WHO Trial (Babor Grant, 1992)
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Project TrEAT (Fleming Barry, 1997)
History of trial Independent investigator-initiat
ed Site 64 FPs, 17 sites, 10 WI
counties Sample Persons seeking
treatment Selection criteria q/f - gt14 and gt11
drinks/week Procedures HSS screening
(n17,695), on-site assessment, 774
randomized Intervention Physician-delivered,
brief Outcome meas. Alcohol use, health,
legal 12 mos. (n723)
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Project TrEAT (Fleming Barry, 1997)
7-Day Alcohol Use (Mean Number of
Drinks per Week)
Men Women Exper. Cont. P
value Exper. Cont. P value Baseline
21.67 21.95 15.05 15.60 6-mos f/up
13.84 17.12 (plt.005) 7.91 11.54 (plt.001) 12-mos
f/up 13.62 16.86 (plt.005) 8.03 13.20 (plt.001)
reduction base-6 mos 36.12 22.02 47.48 2
6.45 base-12 mos 37.16 23.17 46.65 15.89
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Project TrEAT (Fleming, et al, 1998)
Economic Effectiveness of Brief Intervention
Screening intervention cost 177 /
patient Total benefit 1170 /
patient Benefit / cost ratio 66,224 in
benefits for every 10,000 investment
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Current Cigarette Smokers Who Have Received
Advice to Quit From a Health Care Professional
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• Health Care Professionals are
• MOST FREQUENTLY mentioned by the public as the
  ideal source of credible information about
  drugs.
• vs.
• Health Care Professionals are
• LEAST FREQUENTLY mentioned by the public as the
  actual source of information about drugs.

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At-Risk and Problem Drinkers

• Step 1 Give Clear Advice
• State concern about use
• Individualize message
• Advise to change use

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At-Risk and Problem Drinkers

• Step 2 Assess Motivation for Change
• Readiness for change
• Willingness to change

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At-Risk and Problem Drinkers

• Step 3 Establish a Specific Drinking Goal
• Negotiate a specific goal
• Develop a written prescription or contract
• Offer a self-help manual or reading materials

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At-Risk and Problem Drinkers

• Step 4 Follow-up process
• Offer continued support
• Support change efforts with a phone call
• Schedule appointments every three months for at
  least a year

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ASSIST

• Dependent, Medical Problems, and Inability to
  Change
• Step 1 Give Clear Advice
• Step 2 Assess Motivation for Change
• Step 3 Establish a Quit Date
• Step 4 Refer for Assessment or Possible
  Treatment
• Step 5 Follow-up Process

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Dependent Drinkers

• Step 1 Give Clear Advice
• State your concern about use
• Individualize rationale for recommendations
• State need for abstinence

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Dependent Drinkers

• Step 2 Assess Motivation for Change
• Readiness for change
• Willingness to change

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Dependent Drinkers

• Step 3 Establish a Quit Date
• Negotiate a stop date
• Consider detox
• Develop a written contract

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Dependent Drinkers

• Step 4 Referral Process
• Discuss referral options
• Elicit feedback
• Schedule referral appointment
• Communicate with treatment program

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Dependent Drinkers

• Step 5 Follow-up Process
• Support change efforts
• Provide medical care
• Follow-up appointments
• Pharmacotherapy

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Dependent Drinkers

• Pharmacotherapy
• Antabuse
• Naltrexone
• Prozac
• Desipramine
• Co-morbid conditions

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Implementation of Brief Intervention

• Discuss with staff
• Develop protocols
• Assign responsibility
• Assess cost and long-term prevention issues

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Implementation of Brief Intervention (continued)

• Confidentiality Issues
• Record keeping
• Communications between medical providers
• Communication with alcohol treatment specialists
• Diagnosis and billing
• Communication with family and friends
• Communication with insurance companies and
  employers