Evidence of Effect in Trauma Settings
One study of brief interventions analyzed their efficacy at reducing the recurrence of injury in injured adolescents by randomly assigning patients age 18 or 19 years to receive either a 30-minute brief intervention or standard care. At 6-month follow-up, the intervention group had a significant reduction in drinking and driving, moving violations, alcohol-related problems, and less than half as many alcohol-related injuries as patients in the control group.12
Another randomized, prospective, controlled trial was performed on 762 patients admitted to a Level 1 Trauma Center.7 Patients who screened positive were randomized to a single 15–30 minute brief intervention or to a no-intervention control group. At 1-year follow-up, the intervention group decreased their alcohol intake by 22 drinks per week compared to a 2, drink reduction in the conventional care group. A statewide registry was used to detect readmission to any hospital for treatment of an injury over a 3-year follow-up period. There was a 47% reduction in trauma readmissions in the intervention group compared to controls. There was also a 48% reduction in returns to the emergency department for treatment of another injury (Fig. 42-3).
Risk of repeat injury requiring treatment in the Harborview Medical Center, Emergency Department, Seattle Washington (hazard ratio 0.53, 95% CI 0.26–1.07). (Reproduced with permission from Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230(4):473–483.)
Another randomized, prospective trial of brief interventions showed that one driving under the influence (DUI) was prevented for every nine brief interventions performed at 3-year follow-up.13 Through their effect on reducing trauma recurrence, brief interventions have also been shown to result in cost-savings to trauma centers.8 The savings in health care costs over 3 years were $320 per intervention performed and $3.81 for every dollar invested in the screening and brief intervention program.
A best-practice screening model combines both a standardized questionnaire with a laboratory test (urine toxicology screen or blood alcohol test). Patients with a very high BAC or positive toxicology screen should be considered as screening positive. Many physicians are mistrustful of patient self-report, but patients with an alcohol problem do not typically underreport their drinking when asked in a respectful, concerned, and confidential manner.14 Toxicology testing may be a better means of detecting drug use, as patients may be less willing to disclose use of an illegal substance.
A screening questionnaire must be sensitive enough to detect the full spectrum of alcohol problems from mild unhealthy drinking to severe dependence. The Cut down on drinking, Angry when criticized about drinking, Guilty feelings about drinking, Eye-opening morning drinking (CAGE) and Michigan Alcohol Screening Test (MAST) questionnaires have been used for decades, but were primarily designed to detect dependence and are less sensitive to more moderate drinking problems.
The Alcohol Use Disorders Identification Test (AUDIT) is a 10-question, self-report screening tool developed by the World Health Organization, and it has been validated in trauma patients and in numerous languages and cultures15 (Table 42-1). It was designed to be sensitive to a broad spectrum of harmful drinking levels. It assesses drinking quantity and frequency (three questions), problems caused by drinking (two questions), and symptoms of dependence (five questions). It takes less than 2–4 minutes to administer and seconds to score the results.
Table 42-1 The Alcohol Use Disorders Identification Test (Audit) Was Designed to Detect Alcohol Problems Across a Range of Severity, Including Harmful or Nondependent Drinking. |Favorite Table|Download (.pdf)
Table 42-1 The Alcohol Use Disorders Identification Test (Audit) Was Designed to Detect Alcohol Problems Across a Range of Severity, Including Harmful or Nondependent Drinking.
|1. How often do you have a drink containing alcohol?|
|Never||Monthly or less||2–4 times/month||2–3 times/week||≥4 times/week|
|2. How many drinks of alcohol do you have on a typical day when you are drinking?|
|1–2||3–4||5–6||7–9||10 or more|
|3. How often do you have six or more drinks on one occasion?|
|Symptoms of Dependence|
|4. How often during the last year have you found that you were not able to stop drinking once you had started?|
|5. How often during the last year have you failed to do what was normally expected from you because of drinking?|
|6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?|
|7. How often during the last year have you had a feeling of guilt or remorse after drinking?|
|8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?|
|Responses to Questions 3–8|
|Never||Less than monthly||Monthly||Weekly||Daily or almost daily|
|Consequences of Drinking|
|9. Have you or has someone else been injured as a result of your drinking?|
|10. Has a relative, friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?|
|Responses to Questions 9–10|
|No||Yes, but not in the last year||Yes, during the last year|
|Questions 1–8 are scored 0, 1, 2, 3, or 4 points. Questions 9 and 10 are scored 0, 2, or 4 points only. A total score of 8 or more points indicates a strong likelihood of hazardous or harmful alcohol consumption.|
A score of 8 or more is considered to be a positive screen. Because the safe recommended level of alcohol intake is different between males and females, the three quantity and frequency questions decrease the sensitivity of the AUDIT in females, and a lower cutoff score of five points has been recommended.16 Patients who score over 20 points should be considered as being likely to have alcohol dependence and require further assessment and, most likely, a referral to treatment. The AUDIT can often be abbreviated because many patients drink infrequently or not at all. If the answer to question one is zero concerning frequency of use, no further questioning is necessary. The AUDIT is quickly becoming the standard of care in most clinical settings and is widely available in downloadable form.17
At a minimum, reasonably effective screening for drinking above safe guidelines can be performed by asking only one question. In a study of 1,537 patients who presented to the emergency department with an injury, researchers asked the question, “when was the last time you had five or more drinks in one day (more than four drinks for women)?” Formal interviews by trained staff were then conducted to determine if an alcohol problem was present. This single question had sensitivities and specificities of 85 and 70% in males and 82 and 77% in females. This indicates that asking only one straightforward question can be used as a brief screening method. If the patient answers “within the past three months,” then the full AUDIT should be administered.18 Although more time-consuming, the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) is another instrument that was designed to detect and score problems with alcohol, drugs, and tobacco.19
Guidelines for Brief Interventions for Trauma Patients
Most studies of successful brief interventions have used a patient-centered style of motivational counseling derived from Motivational Interviewing. Healthy change occurs when people perceive a large enough discrepancy between the status quo and how they would prefer things to be. It is the clinician’s behavior during the intervention that strongly influences how the patient talks about his or her drinking. An interviewing style of polite and genuine curiosity facilitates change. On the other hand, an interviewing style that the patient experiences as attacking or confrontational provokes resistance and slows down the process.
Research has failed to support the concept that patients with alcohol problems have personality traits such as poor motivation and rigid defense mechanisms such as denial. Rather, these factors are an outcome of the style of interaction between the clinician and patient. When patients “in denial” are heard to argue in favor of the status quo (more drinking), it is usually because he or she has encountered a confrontational or authoritarian counselor. Confrontational tactics are particularly counterproductive in a trauma center because the “denial” they provoke requires too much time and skill to undo.
Application of Brief Intervention
FRAMES. The basic elements of a brief intervention can be summarized by the acronym FRAMES. They consist of providing nonpersonal, concerned Feedback of the patient’s personal risk or impairment related to alcohol consumption; emphasizing their personal Responsibility to change; giving clear Advice that change is needed; and presenting a Menu of alternative strategies that may be appropriate and helpful. This material is presented in an Empathetic manner intended to increase the patient’s sense of Self-efficacy, optimism, and confidence that change is possible.
SUM. Another acronym that has been used to summarize the key components of a brief intervention is SUM or Screening feedback, Understanding the patient’s views, and providing a Menu of change options.
The two main sources of feedback for trauma patients are their BAC upon admission and how their score on a questionnaire compares to established standards. This information can be presented on personalized feedback forms or verbally.
For giving feedback about their BAC a simple five-step acronym is “RANGE.” Tell patients the Range of possible BAC results, from 0 (sober) to 0.6 (fatal). State that All drivers know that 0.08 is the beginning of drunk driving. Normal drinkers stay under 0.05, even when not driving. Then, Give the patient his or her BAC result in relation to 0.08; for example, “Your BAC was 0.16, which is twice the 0.08 figure for drunk driving.” Elicit the patient’s reaction and do not argue. If the patient challenges the validity of the BAC test, the clinician might state, “The best way to explain this is to show you an illustration that indicates that at your blood alcohol concentration of 0.14, you are 48 times more likely to have a serious crash than if you had not been drinking.” It is important for clinicians to tell patients that they are not concerned with labels (alcoholism), “but I am concerned if alcohol is hurting you.”
The goal of an intervention is to establish empathy, not to administer blame. Empathy is the clinician’s primary tool in avoiding resistance or denial. Studies demonstrate that drinking is more likely to be reduced when the counseling style is empathetic, rather than confrontational.
Understanding (from SUM) the patient’s views can be done by asking them about the “pros and cons” of their drinking. After the clinician has listened to and summarized what the patient believes are benefits such as “It helps me to relax,” “It makes it easier to interact with others,” or “It helps me to have a good time,” he or she may ask the patient to explore the “cons” by asking, “What are some of the things you don’t like about drinking?” For example, if the patient indicates that one of the negative aspects of drinking has been frequent arguments with family members, the clinician might ask, “How does your alcohol use affect your ability to have a stable family life?” The goal is to raise doubt by having the patient, rather than the clinician, articulate how alcohol use is having an adverse effect on their family, health, work, finances, driving record, or legal status.
Asking for and then summarizing the pros and cons is a central brief intervention technique. It allows the patient to state the ways that their use of alcohol is adversely affecting them so that recommendations for change are based upon the goals and values that are important to them.
Menus of strategies are offered when the SUMS technique is used. When given a choice the patient is more likely to find an approach that is acceptable to his or her own particular situation. For example, a patient may refuse a referral to formal treatment or to a self-help group, but may be willing to accept an incremental change. Examples would be setting specific limits on their alcohol intake and agreeing to seek further help if they are unable to stay within the negotiated limit. Or, the patient may only be willing to agree to avoid drinking and driving and agree to become involved with a self-help group if they are unable to do so.
The “menu of options” list is most often presented in ascending order of commitment as follows: no change whatsoever, merely think about it and notice more about your drinking in the future, cut down, or quit. If the patient is able to select one of these options, then a plan for obtaining this goal can be discussed. Giving advice is also an important part of the menu. It is appropriate for the clinician to weigh in with an opinion. This usually means offering clear advice to the patient regarding the need to change his or her drinking pattern.
Most studies of brief interventions with positive outcomes have used non–substance abuse specialists. This means that to successfully use these techniques a clinician does not have to have special training and expertise in managing unhealthy substance use. Brief interventions can be performed by anyone who is willing to learn the methods and who is capable of showing respect and concern for injured patients who sometimes drink too much and take dangerous risks.
There are multiple individuals in every trauma center who meet these criteria. The list includes but is not limited to nurses, social workers, physician assistants, psychologists, chaplains, peer-counselors, health educators, and physicians. Although trauma surgeons may obtain the training necessary to perform brief interventions and should have the skills needed to screen and counsel patients with a problem, time demands and staffing constraints will usually prevent them from being the primary providers of this service. The role of the trauma surgeon, however, is critical in providing administrative support through education and advocacy for these services.
Ask, Advise, Assist, Arrange
This acronym is recommended by the National Institute of Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. If the patient is ready to change, the clinician assists in setting goals and agreeing on plans to arrange mechanisms to support these efforts. There is a wealth of information online, including scripts, manuals, and videos.20,21